Provider Demographics
NPI:1295122091
Name:MARDANOVA, AYSYLU (LMSW)
Entity type:Individual
Prefix:
First Name:AYSYLU
Middle Name:
Last Name:MARDANOVA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3311 RIVERVIEW AVE
Mailing Address - Street 2:APT 311
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-8720
Mailing Address - Country:US
Mailing Address - Phone:646-707-6194
Mailing Address - Fax:
Practice Address - Street 1:159 W 127TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-3723
Practice Address - Country:US
Practice Address - Phone:212-752-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY090561-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker