Provider Demographics
NPI:1609128743
Name:KHIYAYEVA, RADA
Entity Type:Individual
Prefix:
First Name:RADA
Middle Name:
Last Name:KHIYAYEVA
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 1:15010 79TH AVE APT 6A
Mailing Address - Street 2:FLUSHING QUEEENS
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-3958
Mailing Address - Country:US
Mailing Address - Phone:917-407-2297
Mailing Address - Fax:
Practice Address - Street 1:15010 79TH AVE APT 6A
Practice Address - Street 2:FLUSHING QUEEENS
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-3958
Practice Address - Country:US
Practice Address - Phone:917-407-2297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-14
Last Update Date:2012-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY679252121252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency