Provider Demographics
NPI:1639312119
Name:SUHOSTAVSKIY, VYACHESLAV (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:VYACHESLAV
Middle Name:
Last Name:SUHOSTAVSKIY
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 BRIGHTWATER AVE
Mailing Address - Street 2:5-D
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-5962
Mailing Address - Country:US
Mailing Address - Phone:917-698-9868
Mailing Address - Fax:718-934-7743
Practice Address - Street 1:236 NEPTUNE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-6302
Practice Address - Country:US
Practice Address - Phone:718-769-2698
Practice Address - Fax:718-769-2317
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-13
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015542225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist