Provider Demographics
NPI:1326287426
Name:DMITRI BOUGAKOV PH.D. PSYCHOLOGY PLLC
Entity Type:Organization
Organization Name:DMITRI BOUGAKOV PH.D. PSYCHOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DMITRI
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUGAKOV
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:646-496-8963
Mailing Address - Street 1:340 E MOSHOLU PKWY S
Mailing Address - Street 2:APARTMENT 6G
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-1742
Mailing Address - Country:US
Mailing Address - Phone:646-496-8963
Mailing Address - Fax:
Practice Address - Street 1:315 W 57TH ST
Practice Address - Street 2:SUITE 401
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-3158
Practice Address - Country:US
Practice Address - Phone:212-541-6412
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-12
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017107103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty