Provider Demographics
NPI:1649677337
Name:USTINOV, YURIY (PHD)
Entity type:Individual
Prefix:
First Name:YURIY
Middle Name:
Last Name:USTINOV
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 CHALLENGER DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-1041
Mailing Address - Country:US
Mailing Address - Phone:207-623-8411
Mailing Address - Fax:
Practice Address - Street 1:3 BAKER ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:ME
Practice Address - Zip Code:04357-1387
Practice Address - Country:US
Practice Address - Phone:512-659-2443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1413103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical