Provider Demographics
NPI:1407684566
Name:BREDOVA, DOMINIKA (MA)
Entity type:Individual
Prefix:
First Name:DOMINIKA
Middle Name:
Last Name:BREDOVA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4306 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-2634
Mailing Address - Country:US
Mailing Address - Phone:929-569-6731
Mailing Address - Fax:
Practice Address - Street 1:159 BLEECKER ST FL 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-1457
Practice Address - Country:US
Practice Address - Phone:929-400-7481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health