Provider Demographics
NPI:1356603070
Name:BOGOMOLNAYA, VIKTORIYA (TSLD)
Entity type:Individual
Prefix:
First Name:VIKTORIYA
Middle Name:
Last Name:BOGOMOLNAYA
Suffix:
Gender:F
Credentials:TSLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 TREETOP CRES
Mailing Address - Street 2:
Mailing Address - City:RYE BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:10573-1645
Mailing Address - Country:US
Mailing Address - Phone:347-210-0223
Mailing Address - Fax:
Practice Address - Street 1:241 TREETOP CRES
Practice Address - Street 2:
Practice Address - City:RYE BROOK
Practice Address - State:NY
Practice Address - Zip Code:10573-1645
Practice Address - Country:US
Practice Address - Phone:347-210-0223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-08
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY540459111174400000X
NY0220033235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY174400000XOtherTEACHER