Provider Demographics
NPI:1265797096
Name:FUNCTIONAL LIFE
Entity type:Organization
Organization Name:FUNCTIONAL LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPECIAL EDUCATION TEACHER
Authorized Official - Prefix:
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAFAELOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-412-7796
Mailing Address - Street 1:8110 135TH ST APT 201
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435-1041
Mailing Address - Country:US
Mailing Address - Phone:917-412-7796
Mailing Address - Fax:
Practice Address - Street 1:8110 135TH ST APT 201
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435-1041
Practice Address - Country:US
Practice Address - Phone:917-412-7796
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency