Provider Demographics
NPI:1215232194
Name:FAKHERIAN, ILANA (PT)
Entity Type:Individual
Prefix:
First Name:ILANA
Middle Name:
Last Name:FAKHERIAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3124 AVENUE P
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-3408
Mailing Address - Country:US
Mailing Address - Phone:718-419-9664
Mailing Address - Fax:
Practice Address - Street 1:3124 AVENUE P
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-3408
Practice Address - Country:US
Practice Address - Phone:718-419-9664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-24
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist