Provider Demographics
NPI:1386192904
Name:LAVERDURE, JEREMY ANTHONY (DPT)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:ANTHONY
Last Name:LAVERDURE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 UNIVERSITY PL
Mailing Address - Street 2:FL 8
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-4515
Mailing Address - Country:US
Mailing Address - Phone:212-604-1316
Mailing Address - Fax:646-251-8025
Practice Address - Street 1:3244 36TH ST
Practice Address - Street 2:APT. 3
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106-1170
Practice Address - Country:US
Practice Address - Phone:646-339-3052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040472225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist