Provider Demographics
NPI:1912241852
Name:TEITELBAUM, BASHA (MSED)
Entity type:Individual
Prefix:
First Name:BASHA
Middle Name:
Last Name:TEITELBAUM
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5614 15TH AVE
Mailing Address - Street 2:#5F
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-4750
Mailing Address - Country:US
Mailing Address - Phone:718-853-5126
Mailing Address - Fax:718-514-8693
Practice Address - Street 1:5614 15TH AVE
Practice Address - Street 2:#5F
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-4750
Practice Address - Country:US
Practice Address - Phone:718-853-5126
Practice Address - Fax:718-514-8693
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist