Provider Demographics
NPI:1346059946
Name:YTSHAKOV, AVIGAIL MIRIAM
Entity type:Individual
Prefix:
First Name:AVIGAIL
Middle Name:MIRIAM
Last Name:YTSHAKOV
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 1:1016 DICKENS ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-2407
Mailing Address - Country:US
Mailing Address - Phone:646-421-0414
Mailing Address - Fax:
Practice Address - Street 1:999 CENTRAL AVE STE 308
Practice Address - Street 2:
Practice Address - City:WOODMERE
Practice Address - State:NY
Practice Address - Zip Code:11598-1205
Practice Address - Country:US
Practice Address - Phone:516-374-7914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist