Provider Demographics
NPI:1215576293
Name:FEVELO, MARISSA J (DPT)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:J
Last Name:FEVELO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 5TH AVE FL 6
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6575
Mailing Address - Country:US
Mailing Address - Phone:212-759-2282
Mailing Address - Fax:212-379-2123
Practice Address - Street 1:30 BROAD ST # STREETA
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10004-2304
Practice Address - Country:US
Practice Address - Phone:646-790-7454
Practice Address - Fax:212-379-2076
Is Sole Proprietor?:No
Enumeration Date:2019-12-23
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0134120225100000X
LA10470R225100000X
NY044865225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist