Provider Demographics
NPI:1376823583
Name:MOGRACHYOVA, POLINA (MS ED)
Entity Type:Individual
Prefix:
First Name:POLINA
Middle Name:
Last Name:MOGRACHYOVA
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:456 AVENUE V
Mailing Address - Street 2:GROUND FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-4839
Mailing Address - Country:US
Mailing Address - Phone:347-733-7380
Mailing Address - Fax:
Practice Address - Street 1:456 AVENUE V
Practice Address - Street 2:GROUND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-4839
Practice Address - Country:US
Practice Address - Phone:347-733-7380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1151826222Q00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No174400000XOther Service ProvidersSpecialist