Provider Demographics
NPI:1154098267
Name:YUMATOV, ROMAN (MA)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:YUMATOV
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:ROMAN
Other - Middle Name:
Other - Last Name:YUMATOV ANDRADE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:3075 BRIGHTON 14TH ST APT 34A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-5530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3075 BRIGHTON 14TH ST APT 34A
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-5530
Practice Address - Country:US
Practice Address - Phone:917-602-5680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001056102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst