Provider Demographics
NPI:1487185658
Name:PETUKHOVA, ANASTASIA (SC)
Entity Type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:
Last Name:PETUKHOVA
Suffix:
Gender:F
Credentials:SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2148 OCEAN AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-1406
Mailing Address - Country:US
Mailing Address - Phone:718-375-2505
Mailing Address - Fax:718-375-2472
Practice Address - Street 1:2148 OCEAN AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1406
Practice Address - Country:US
Practice Address - Phone:718-375-2505
Practice Address - Fax:718-375-2472
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator