Provider Demographics
NPI:1154683621
Name:SIONOV, MIRA
Entity Type:Individual
Prefix:MRS
First Name:MIRA
Middle Name:
Last Name:SIONOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRA
Other - Middle Name:
Other - Last Name:FUZAYLOVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:649 39TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11232-3101
Mailing Address - Country:US
Mailing Address - Phone:718-851-3300
Mailing Address - Fax:718-972-0696
Practice Address - Street 1:649 39TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11232-3101
Practice Address - Country:US
Practice Address - Phone:718-851-3300
Practice Address - Fax:718-972-0696
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator