Provider Demographics
NPI:1124835475
Name:KHODAKOVSKI, MARIA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:KHODAKOVSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7292 STATE ROUTE 42
Mailing Address - Street 2:
Mailing Address - City:GRAHAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12740-7004
Mailing Address - Country:US
Mailing Address - Phone:845-707-3933
Mailing Address - Fax:
Practice Address - Street 1:2 HIGH ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-1343
Practice Address - Country:US
Practice Address - Phone:845-791-8800
Practice Address - Fax:845-791-7051
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-11
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY554618-01163WP0808X
NYF407294363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health