Provider Demographics
NPI:1316196173
Name:HAFISOV, YELENA
Entity Type:Individual
Prefix:
First Name:YELENA
Middle Name:
Last Name:HAFISOV
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 1:1455 55TH ST
Mailing Address - Street 2:APARTMENT 4D
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-4257
Mailing Address - Country:US
Mailing Address - Phone:718-435-9472
Mailing Address - Fax:
Practice Address - Street 1:1221 E 14TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-4803
Practice Address - Country:US
Practice Address - Phone:718-434-4600
Practice Address - Fax:718-434-6261
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014740-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist