Provider Demographics
NPI:1275784761
Name:TAKHALOV, MARINA
Entity Type:Individual
Prefix:MRS
First Name:MARINA
Middle Name:
Last Name:TAKHALOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARINA
Other - Middle Name:
Other - Last Name:TSIFRINOVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 BELLE TERRE RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1928
Mailing Address - Country:US
Mailing Address - Phone:631-474-6111
Mailing Address - Fax:631-474-6861
Practice Address - Street 1:200 BELLE TERRE RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1928
Practice Address - Country:US
Practice Address - Phone:631-474-6111
Practice Address - Fax:631-474-6861
Is Sole Proprietor?:No
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017417235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist