Provider Demographics
NPI:1376917484
Name:AREVALO, KRISTIN (ASSOCIATES DEGREE)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:AREVALO
Suffix:
Gender:F
Credentials:ASSOCIATES DEGREE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 N BROOME AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-4130
Mailing Address - Country:US
Mailing Address - Phone:516-477-9456
Mailing Address - Fax:
Practice Address - Street 1:72 S WOODS RD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-1024
Practice Address - Country:US
Practice Address - Phone:516-921-7650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010109-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant