Provider Demographics
NPI:1174885867
Name:RYBALOV, OLEG
Entity type:Individual
Prefix:MR
First Name:OLEG
Middle Name:
Last Name:RYBALOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2388 OCEAN AVE
Mailing Address - Street 2:APT. 7
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-3564
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2388 OCEAN AVE
Practice Address - Street 2:APT. 7
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-3564
Practice Address - Country:US
Practice Address - Phone:191-741-7734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-09
Last Update Date:2013-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY612156121174400000X
NY022591235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No174400000XOther Service ProvidersSpecialist