Basic Information
| Provider Information | |||||||||
| NPI: | 1639505894 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALBA | ||||||||
| FirstName: | YANIRIS | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5225 NEW UTRECHT AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112193846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187627633 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5225 NEW UTRECHT AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112193846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187627633 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2013 | ||||||||
| LastUpdateDate: | 07/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 06/09/2022 | ||||||||
| NPIReactivationDate: | 07/22/2022 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 252Y00000X | 2130948 | NY | N | Agencies | Early Intervention Provider Agency | 103TS0200X | NY | Y | Behavioral Health & Social Service Providers | Psychologist | School |
No ID Information.