Provider Demographics
NPI:1962948570
Name:DETCHKOV, KONSTANTIN
Entity type:Individual
Prefix:
First Name:KONSTANTIN
Middle Name:
Last Name:DETCHKOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3280 RESERVOIR OVAL E APT A6
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-3146
Mailing Address - Country:US
Mailing Address - Phone:347-337-2436
Mailing Address - Fax:
Practice Address - Street 1:3280 RESERVOIR OVAL E APT A6
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-3146
Practice Address - Country:US
Practice Address - Phone:347-337-2436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-06
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY090368104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker