Provider Demographics
NPI:1073927760
Name:OSTROV, EVELINA
Entity Type:Individual
Prefix:MRS
First Name:EVELINA
Middle Name:
Last Name:OSTROV
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 1:319 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-5222
Mailing Address - Country:US
Mailing Address - Phone:917-216-2085
Mailing Address - Fax:
Practice Address - Street 1:319 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-5222
Practice Address - Country:US
Practice Address - Phone:917-216-2085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY613405121103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool