Provider Demographics
NPI:1740694587
Name:BARDANOVA, NELLI
Entity type:Individual
Prefix:MRS
First Name:NELLI
Middle Name:
Last Name:BARDANOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NELLI
Other - Middle Name:
Other - Last Name:BARDANOVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR
Mailing Address - Street 1:9805 63RD RD
Mailing Address - Street 2:APT 5B
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1744
Mailing Address - Country:US
Mailing Address - Phone:917-679-2040
Mailing Address - Fax:
Practice Address - Street 1:7907 METROPOLITAN AVE
Practice Address - Street 2:
Practice Address - City:MIDDLE VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11379-2930
Practice Address - Country:US
Practice Address - Phone:917-745-0470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018931225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04299161Medicaid