Provider Demographics
NPI:1194087700
Name:THEODOSIADOU, THEODORA
Entity type:Individual
Prefix:
First Name:THEODORA
Middle Name:
Last Name:THEODOSIADOU
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 1:4515 172ND ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-3335
Mailing Address - Country:US
Mailing Address - Phone:917-868-6585
Mailing Address - Fax:
Practice Address - Street 1:4515 172ND ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358-3335
Practice Address - Country:US
Practice Address - Phone:917-868-6585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-10
Last Update Date:2012-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X, 252Y00000X
NYCOOPERKIDSTHERAPYASS252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No252Y00000XAgenciesEarly Intervention Provider Agency