Provider Demographics
NPI:1659633048
Name:PUSTOVIT, TETYANA
Entity Type:Individual
Prefix:MS
First Name:TETYANA
Middle Name:
Last Name:PUSTOVIT
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 1:1580 DAHILL RD
Mailing Address - Street 2:2 FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-3537
Mailing Address - Country:US
Mailing Address - Phone:718-375-2505
Mailing Address - Fax:718-375-2472
Practice Address - Street 1:1580 DAHILL RD
Practice Address - Street 2:2 FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-3537
Practice Address - Country:US
Practice Address - Phone:718-375-2505
Practice Address - Fax:718-375-2472
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY16442171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator