Provider Demographics
NPI:1861833626
Name:ILYASOVA, MARIANNA (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:MARIANNA
Middle Name:
Last Name:ILYASOVA
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13526 78TH AVE
Mailing Address - Street 2:#F
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-3286
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13526 78TH AVE
Practice Address - Street 2:#F
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-3286
Practice Address - Country:US
Practice Address - Phone:347-265-3064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017831-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist