Provider Demographics
NPI:1215299201
Name:SHIMUNOVA, KSENIYA (OTR/L)
Entity type:Individual
Prefix:
First Name:KSENIYA
Middle Name:
Last Name:SHIMUNOVA
Suffix:
Gender:F
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 1:9110 146TH ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435-4301
Mailing Address - Country:US
Mailing Address - Phone:718-464-2017
Mailing Address - Fax:
Practice Address - Street 1:10240 62ND AVE APT 3E
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1031
Practice Address - Country:US
Practice Address - Phone:718-592-7234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017227-1251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services