Provider Demographics
NPI:1689003485
Name:KATANOV, BORIS (MASTERS)
Entity Type:Individual
Prefix:
First Name:BORIS
Middle Name:
Last Name:KATANOV
Suffix:
Gender:M
Credentials:MASTERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9826 64TH AVE APT 6F
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2509
Mailing Address - Country:US
Mailing Address - Phone:347-527-6176
Mailing Address - Fax:
Practice Address - Street 1:13411 KEW GARDENS RD
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-1930
Practice Address - Country:US
Practice Address - Phone:718-441-0155
Practice Address - Fax:347-571-6606
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1367355222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist