Provider Demographics
NPI:1013935832
Name:KLEBANOV, BORIS (LCSW)
Entity Type:Individual
Prefix:MR
First Name:BORIS
Middle Name:
Last Name:KLEBANOV
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 OCEANA DR W APT 4D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-6667
Mailing Address - Country:US
Mailing Address - Phone:718-934-7493
Mailing Address - Fax:
Practice Address - Street 1:40 OCEANA DR W APT 4D
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-6667
Practice Address - Country:US
Practice Address - Phone:718-934-7493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065145-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN5X951Medicare ID - Type Unspecified