Provider Demographics
NPI:1457105140
Name:ILYASOVA, MARY ALEXANDRA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALEXANDRA
Last Name:ILYASOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7925 150TH ST APT C22
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-3808
Mailing Address - Country:US
Mailing Address - Phone:646-620-7732
Mailing Address - Fax:
Practice Address - Street 1:7925 150TH ST APT C22
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-3808
Practice Address - Country:US
Practice Address - Phone:646-620-7732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist