Provider Demographics
NPI:1033209259
Name:MACHNIKOFF, TINA ELLEN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:ELLEN
Last Name:MACHNIKOFF
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24302 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:DOUGLASTON
Mailing Address - State:NY
Mailing Address - Zip Code:11362-1150
Mailing Address - Country:US
Mailing Address - Phone:718-423-6200
Mailing Address - Fax:718-423-9762
Practice Address - Street 1:24302 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:DOUGLASTON
Practice Address - State:NY
Practice Address - Zip Code:11362-1150
Practice Address - Country:US
Practice Address - Phone:718-423-6200
Practice Address - Fax:718-423-9762
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR054117-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0118EBMedicare ID - Type UnspecifiedIND. NUMBER IN GROUP