Provider Demographics
NPI:1689161820
Name:RAFAELOV, ILANIT
Entity Type:Individual
Prefix:
First Name:ILANIT
Middle Name:
Last Name:RAFAELOV
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 1:50-28 UTOPIA PKWY
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365
Mailing Address - Country:US
Mailing Address - Phone:917-214-5244
Mailing Address - Fax:
Practice Address - Street 1:50-28 UTOPIA PKWY
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-1136
Practice Address - Country:US
Practice Address - Phone:917-214-5244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1218608181252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency