Provider Demographics
NPI:1578592200
Name:TIMOFF-KISSIN, TATYANA (LCSW)
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:TIMOFF-KISSIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 W 72ND ST APT 1E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-3419
Mailing Address - Country:US
Mailing Address - Phone:917-680-6121
Mailing Address - Fax:
Practice Address - Street 1:15 W 72ND ST APT 1E
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-3419
Practice Address - Country:US
Practice Address - Phone:917-680-6121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR045989-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN48Y41Medicare ID - Type Unspecified
NY01824Medicare ID - Type Unspecified