Provider Demographics
NPI:1114416559
Name:GERVAIS, PRINCESSA
Entity Type:Individual
Prefix:
First Name:PRINCESSA
Middle Name:
Last Name:GERVAIS
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 1:21232 113TH AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11429-2318
Mailing Address - Country:US
Mailing Address - Phone:347-400-0145
Mailing Address - Fax:
Practice Address - Street 1:21232 113TH AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11429-2318
Practice Address - Country:US
Practice Address - Phone:347-400-0145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0996571104100000X, 1041S0200X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Multi-Specialty