Provider Demographics
NPI:1073389946
Name:SHRIVASTAVA, MARCEY
Entity Type:Individual
Prefix:
First Name:MARCEY
Middle Name:
Last Name:SHRIVASTAVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 SR 92 N
Mailing Address - Street 2:
Mailing Address - City:TUNKHANNOCK
Mailing Address - State:PA
Mailing Address - Zip Code:18657-5614
Mailing Address - Country:US
Mailing Address - Phone:570-240-7400
Mailing Address - Fax:
Practice Address - Street 1:515 SR 92 N
Practice Address - Street 2:
Practice Address - City:TUNKHANNOCK
Practice Address - State:PA
Practice Address - Zip Code:18657-5614
Practice Address - Country:US
Practice Address - Phone:570-240-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT-007720-L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist