Provider Demographics
NPI:1639312770
Name:GAVRIELOV, LINDA (RD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:GAVRIELOV
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 GLENBROOK RD APT 41C
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06906-2527
Mailing Address - Country:US
Mailing Address - Phone:917-658-3012
Mailing Address - Fax:
Practice Address - Street 1:10460 QUEENS BLVD
Practice Address - Street 2:APT 22G
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7301
Practice Address - Country:US
Practice Address - Phone:917-658-3012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-17
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
NY006739-1133V00000X
CT001284133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered