Provider Demographics
NPI:1346475878
Name:NAKHUTINA, LUBA (PHD)
Entity Type:Individual
Prefix:
First Name:LUBA
Middle Name:
Last Name:NAKHUTINA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 W 181ST ST
Mailing Address - Street 2:5A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-4469
Mailing Address - Country:US
Mailing Address - Phone:917-740-8195
Mailing Address - Fax:212-297-0536
Practice Address - Street 1:305 MADISON AVE
Practice Address - Street 2:SUITE 1060
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10165-0006
Practice Address - Country:US
Practice Address - Phone:917-740-8195
Practice Address - Fax:212-297-0536
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2016-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017696-1103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400074185Medicare PIN