Provider Demographics
NPI:1699981563
Name:PRUSAKOVA, YEVGENIYA SAFRONOVNA (SLP)
Entity type:Individual
Prefix:MRS
First Name:YEVGENIYA
Middle Name:SAFRONOVNA
Last Name:PRUSAKOVA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6308 SHELTER CREEK LN
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-3871
Mailing Address - Country:US
Mailing Address - Phone:650-616-8738
Mailing Address - Fax:
Practice Address - Street 1:6308 SHELTER CREEK LN
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-3871
Practice Address - Country:US
Practice Address - Phone:650-616-8738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP15602235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist