Provider Demographics
NPI:1366133753
Name:BABOOLAL-FONG, NYLA
Entity type:Individual
Prefix:MRS
First Name:NYLA
Middle Name:
Last Name:BABOOLAL-FONG
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 1:10041 200TH ST
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-3330
Mailing Address - Country:US
Mailing Address - Phone:917-608-5823
Mailing Address - Fax:
Practice Address - Street 1:100 DUFFY AVE STE 510
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-3636
Practice Address - Country:US
Practice Address - Phone:516-881-5373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002305103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst