Provider Demographics
NPI:1740855782
Name:VOLOKH, LARISA
Entity type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:VOLOKH
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 1:39 GAIL DRIVE
Mailing Address - Street 2:APT B
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960
Mailing Address - Country:US
Mailing Address - Phone:585-721-2604
Mailing Address - Fax:
Practice Address - Street 1:11 WILBUR RD
Practice Address - Street 2:
Practice Address - City:THIELLS
Practice Address - State:NY
Practice Address - Zip Code:10984-7555
Practice Address - Country:US
Practice Address - Phone:585-721-2604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86101181133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered