Provider Demographics
NPI:1568010486
Name:ZAKHAROVA, KSENIA
Entity Type:Individual
Prefix:
First Name:KSENIA
Middle Name:
Last Name:ZAKHAROVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 VILLAGE GREEN LN APT 2064
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-2472
Mailing Address - Country:US
Mailing Address - Phone:248-820-1089
Mailing Address - Fax:
Practice Address - Street 1:955 CAMPUS DR N
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-2754
Practice Address - Country:US
Practice Address - Phone:248-475-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty