Provider Demographics
NPI:1891237087
Name:KUSHNIROVICH, LYA (PSYD)
Entity Type:Individual
Prefix:
First Name:LYA
Middle Name:
Last Name:KUSHNIROVICH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4832 COBIA DR SE
Mailing Address - Street 2:APT B
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-4896
Mailing Address - Country:US
Mailing Address - Phone:917-837-1747
Mailing Address - Fax:
Practice Address - Street 1:3250 ZEMKE AVE BLDG 1078
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33621-5023
Practice Address - Country:US
Practice Address - Phone:813-827-9170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-05
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 9734103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1386694701OtherJAMES A. HALEY VA