Provider Demographics
NPI:1710107735
Name:BAKIS, SVYATOSLAV (LCSW)
Entity Type:Individual
Prefix:DR
First Name:SVYATOSLAV
Middle Name:
Last Name:BAKIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 MALLORY AVE
Mailing Address - Street 2:B
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-4200
Mailing Address - Country:US
Mailing Address - Phone:718-876-6226
Mailing Address - Fax:
Practice Address - Street 1:745 64TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-4753
Practice Address - Country:US
Practice Address - Phone:718-283-1913
Practice Address - Fax:718-635-6745
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052698-1103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY052698-1OtherLCSW