Provider Demographics
NPI:1245606052
Name:DELAFRAZ, FARIBA
Entity Type:Individual
Prefix:MS
First Name:FARIBA
Middle Name:
Last Name:DELAFRAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023-1218
Mailing Address - Country:US
Mailing Address - Phone:516-655-5960
Mailing Address - Fax:
Practice Address - Street 1:255 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-1718
Practice Address - Country:US
Practice Address - Phone:516-576-2040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-16
Last Update Date:2015-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY605512693171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator