Provider Demographics
NPI:1063940385
Name:YEFIMOVA, LIZA
Entity type:Individual
Prefix:
First Name:LIZA
Middle Name:
Last Name:YEFIMOVA
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 1:578 TRAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-4802
Mailing Address - Country:US
Mailing Address - Phone:646-578-0612
Mailing Address - Fax:
Practice Address - Street 1:578 TRAVIS AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-4802
Practice Address - Country:US
Practice Address - Phone:646-578-0612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-31
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY251300000XMedicaid