Provider Demographics
NPI:1316510951
Name:BOLOTOVSKAYA, YUDIT
Entity type:Individual
Prefix:
First Name:YUDIT
Middle Name:
Last Name:BOLOTOVSKAYA
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 1:446 E 86TH ST APT 11A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-6472
Mailing Address - Country:US
Mailing Address - Phone:617-595-0553
Mailing Address - Fax:
Practice Address - Street 1:10 AMBER LN
Practice Address - Street 2:
Practice Address - City:OYSTER BAY
Practice Address - State:NY
Practice Address - Zip Code:11771-3115
Practice Address - Country:US
Practice Address - Phone:347-270-8850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA78157235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist