Provider Demographics
NPI:1477610673
Name:KOULOMZIN, MARINA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARINA
Middle Name:
Last Name:KOULOMZIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:MARINA
Other - Middle Name:
Other - Last Name:KOULOMZIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:5700 ARLINGTON AVE
Mailing Address - Street 2:APT 20M
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10471-1503
Mailing Address - Country:US
Mailing Address - Phone:718-432-0674
Mailing Address - Fax:718-432-0674
Practice Address - Street 1:5700 ARLINGTON AVE
Practice Address - Street 2:APT 20L
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10471-1503
Practice Address - Country:US
Practice Address - Phone:718-432-0674
Practice Address - Fax:718-432-0674
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012561103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV846V1Medicare ID - Type Unspecified