Provider Demographics
NPI:1194814756
Name:MASTYAYEVA, YEVGENIA (PHD, LCSW)
Entity Type:Individual
Prefix:
First Name:YEVGENIA
Middle Name:
Last Name:MASTYAYEVA
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5110 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-3424
Mailing Address - Country:US
Mailing Address - Phone:800-275-3243
Mailing Address - Fax:800-275-3671
Practice Address - Street 1:2020 CONEY ISLAND AVE
Practice Address - Street 2:JBFCS, MID-BROOKLYN CLINIC
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-2329
Practice Address - Country:US
Practice Address - Phone:718-676-4230
Practice Address - Fax:718-676-4216
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018503-1103TC0700X
NY0461161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN8B441Medicare ID - Type Unspecified