Provider Demographics
NPI:1538407259
Name:INDIVIDUAL PROVIDER
Entity type:Organization
Organization Name:INDIVIDUAL PROVIDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPECIAL ED. TEACHER
Authorized Official - Prefix:MS
Authorized Official - First Name:LARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MISHINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-612-5231
Mailing Address - Street 1:3031 BRIGHTON 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-8017
Mailing Address - Country:US
Mailing Address - Phone:917-612-5231
Mailing Address - Fax:
Practice Address - Street 1:3031 BRIGHTON 1ST ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-8017
Practice Address - Country:US
Practice Address - Phone:917-612-5231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-30
Last Update Date:2013-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty