Provider Demographics
NPI:1780260018
Name:ILYASOV, MIKHAIL (OTR/L)
Entity type:Individual
Prefix:
First Name:MIKHAIL
Middle Name:
Last Name:ILYASOV
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14765 HOOVER AVE
Mailing Address - Street 2:
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-2139
Mailing Address - Country:US
Mailing Address - Phone:718-612-5634
Mailing Address - Fax:718-275-2686
Practice Address - Street 1:9508 QUEENS BLVD STE 1E
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-1151
Practice Address - Country:US
Practice Address - Phone:718-275-2669
Practice Address - Fax:718-275-2686
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025495225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist