Provider Demographics
NPI:1275198947
Name:BYSTROVA, ANASTASIIA (MS ECE (B-2ND G))
Entity Type:Individual
Prefix:
First Name:ANASTASIIA
Middle Name:
Last Name:BYSTROVA
Suffix:
Gender:F
Credentials:MS ECE (B-2ND G)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2483 W 16TH ST APT 2G
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-7019
Mailing Address - Country:US
Mailing Address - Phone:347-500-2276
Mailing Address - Fax:
Practice Address - Street 1:2483 W 16TH ST APT 2G
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-7019
Practice Address - Country:US
Practice Address - Phone:347-500-2276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1271696181222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist