Provider Demographics
NPI:1114346483
Name:KHASINA, BERTA (MSED)
Entity Type:Individual
Prefix:MISS
First Name:BERTA
Middle Name:
Last Name:KHASINA
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2775 W. 5TH ST.
Mailing Address - Street 2:21G
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-4161
Mailing Address - Country:US
Mailing Address - Phone:347-827-7284
Mailing Address - Fax:
Practice Address - Street 1:236 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-2704
Practice Address - Country:US
Practice Address - Phone:212-683-8906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2522112174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist