Provider Demographics
NPI:1801103585
Name:DAVYDOVA, ALENA R
Entity type:Individual
Prefix:
First Name:ALENA
Middle Name:R
Last Name:DAVYDOVA
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 1:1773 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-1145
Mailing Address - Country:US
Mailing Address - Phone:718-372-8669
Mailing Address - Fax:
Practice Address - Street 1:11945 UNION TPKE
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-6144
Practice Address - Country:US
Practice Address - Phone:718-263-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVB21170RMedicaid