Provider Demographics
NPI:1235792987
Name:KULISHOV, IGOR
Entity Type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:KULISHOV
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 1:1664 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1155
Mailing Address - Country:US
Mailing Address - Phone:718-954-3800
Mailing Address - Fax:
Practice Address - Street 1:1623 KINGS HIGHWAY, BROOKLYN, NY 11229
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229
Practice Address - Country:US
Practice Address - Phone:718-954-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health