Provider Demographics
NPI:1235550427
Name:GAVELA, VIVIANA
Entity Type:Individual
Prefix:
First Name:VIVIANA
Middle Name:
Last Name:GAVELA
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 1:6261 BOOTH ST
Mailing Address - Street 2:FLOOR 2
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1561
Mailing Address - Country:US
Mailing Address - Phone:646-234-5063
Mailing Address - Fax:
Practice Address - Street 1:1100 CONEY ISLAND AVE
Practice Address - Street 2:SUITE 414
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-2344
Practice Address - Country:US
Practice Address - Phone:718-434-1200
Practice Address - Fax:718-434-1099
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-15
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210385252Y00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No174400000XOther Service ProvidersSpecialist