Basic Information
| Provider Information | |||||||||
| NPI: | 1760747489 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHAIMOV | ||||||||
| FirstName: | ANGELICA | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6941 183RD ST | ||||||||
| Address2: | |||||||||
| City: | FRESH MEADOWS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113653535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189694972 | ||||||||
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| Practice Location | |||||||||
| Address1: | 24302 NORTHERN BLVD | ||||||||
| Address2: | |||||||||
| City: | DOUGLASTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113621150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184236200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2012 | ||||||||
| LastUpdateDate: | 07/09/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 086491 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.