Provider Demographics
NPI:1760747489
Name:KHAIMOV, ANGELICA I (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:ANGELICA
Middle Name:I
Last Name:KHAIMOV
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6941 183RD ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-3535
Mailing Address - Country:US
Mailing Address - Phone:718-969-4972
Mailing Address - Fax:
Practice Address - Street 1:24302 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:DOUGLASTON
Practice Address - State:NY
Practice Address - Zip Code:11362-1150
Practice Address - Country:US
Practice Address - Phone:718-423-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY086491104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker