Provider Demographics
NPI:1851690267
Name:KRAVETSKIY, ILYA
Entity Type:Individual
Prefix:
First Name:ILYA
Middle Name:
Last Name:KRAVETSKIY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-4343
Mailing Address - Country:US
Mailing Address - Phone:917-757-1965
Mailing Address - Fax:
Practice Address - Street 1:1599 E 15TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-6759
Practice Address - Country:US
Practice Address - Phone:718-676-1743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011492225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist