Provider Demographics
NPI:1285211961
Name:GERASSIMOV, ILIA (LMT)
Entity Type:Individual
Prefix:
First Name:ILIA
Middle Name:
Last Name:GERASSIMOV
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE FERRY
Mailing Address - State:NJ
Mailing Address - Zip Code:07643-1803
Mailing Address - Country:US
Mailing Address - Phone:718-506-4515
Mailing Address - Fax:
Practice Address - Street 1:14 CENTER ST
Practice Address - Street 2:
Practice Address - City:LITTLE FERRY
Practice Address - State:NJ
Practice Address - Zip Code:07643-1803
Practice Address - Country:US
Practice Address - Phone:718-506-4515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-27
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024648225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist