Provider Demographics
NPI:1265052807
Name:IORDANOVA, ELISSAVETA G (LCAT)
Entity type:Individual
Prefix:
First Name:ELISSAVETA
Middle Name:G
Last Name:IORDANOVA
Suffix:
Gender:F
Credentials:LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2588 AC POWELL BLVD APT 3M
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10039-2607
Mailing Address - Country:US
Mailing Address - Phone:917-848-7199
Mailing Address - Fax:
Practice Address - Street 1:2588 AC POWELL BLVD APT 3M
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10039-2607
Practice Address - Country:US
Practice Address - Phone:917-848-7199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002141-1225600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9046310213Other1199