Provider Demographics
NPI:1063103968
Name:TATIKOLA, MAYA
Entity type:Individual
Prefix:
First Name:MAYA
Middle Name:
Last Name:TATIKOLA
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 1:4751 40TH ST APT 3G
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-4032
Mailing Address - Country:US
Mailing Address - Phone:908-448-8771
Mailing Address - Fax:
Practice Address - Street 1:92 PROSPECT PL
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-5121
Practice Address - Country:US
Practice Address - Phone:908-448-8771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117573104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker