Provider Demographics
NPI:1942562566
Name:BORUKHOVA, SVETLANA
Entity Type:Individual
Prefix:
First Name:SVETLANA
Middle Name:
Last Name:BORUKHOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6505 ALDERTON ST
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-5013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6505 ALDERTON ST
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-5013
Practice Address - Country:US
Practice Address - Phone:646-420-9939
Practice Address - Fax:718-896-8890
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-10
Last Update Date:2012-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
17440000X0OtherCHALLENGE EARLY INTERVENTION