Provider Demographics
NPI:1720367816
Name:TELZAK, CAROL (MA)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:TELZAK
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 ERROLL PL
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10804-3508
Mailing Address - Country:US
Mailing Address - Phone:914-636-3837
Mailing Address - Fax:
Practice Address - Street 1:30 ERROLL PL
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10804-3508
Practice Address - Country:US
Practice Address - Phone:914-636-3837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001614-1251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01395326Medicaid