Provider Demographics
NPI:1407140601
Name:GONZALVO, STEVENSON SAGA (OTR/L)
Entity Type:Individual
Prefix:
First Name:STEVENSON
Middle Name:SAGA
Last Name:GONZALVO
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 WOOD ST
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-2466
Mailing Address - Country:US
Mailing Address - Phone:516-643-4034
Mailing Address - Fax:516-433-3720
Practice Address - Street 1:21111 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3241
Practice Address - Country:US
Practice Address - Phone:718-705-1018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-05
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013879-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist