Provider Demographics
NPI:1013181478
Name:GURBELOSHVILI, KATYA (SLP)
Entity Type:Individual
Prefix:MISS
First Name:KATYA
Middle Name:
Last Name:GURBELOSHVILI
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 LARK AVE
Mailing Address - Street 2:
Mailing Address - City:OLD BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11804-1411
Mailing Address - Country:US
Mailing Address - Phone:516-293-0736
Mailing Address - Fax:
Practice Address - Street 1:11 LARK AVE
Practice Address - Street 2:
Practice Address - City:OLD BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11804-1411
Practice Address - Country:US
Practice Address - Phone:516-293-0736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2162342235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist