Provider Demographics
NPI:1669821823
Name:IFRAIMOVA, VIOLETTA (SPECIAL EDUCATOR)
Entity Type:Individual
Prefix:
First Name:VIOLETTA
Middle Name:
Last Name:IFRAIMOVA
Suffix:
Gender:F
Credentials:SPECIAL EDUCATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 OCEAN PKWY
Mailing Address - Street 2:APT #4B
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-7067
Mailing Address - Country:US
Mailing Address - Phone:917-693-5946
Mailing Address - Fax:
Practice Address - Street 1:1600 OCEAN PKWY
Practice Address - Street 2:APT #4B
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-7067
Practice Address - Country:US
Practice Address - Phone:917-693-5946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2613983171M00000X, 174400000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes174400000XOther Service ProvidersSpecialist