Provider Demographics
NPI:1497811889
Name:WIVELL, ELIZABETH ANN (OTR/L, LAC , DACM)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ANN
Last Name:WIVELL
Suffix:
Gender:F
Credentials:OTR/L, LAC , DACM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 STUYVESANT OVAL
Mailing Address - Street 2:APT 9G
Mailing Address - City:NEW YORK CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10009
Mailing Address - Country:US
Mailing Address - Phone:917-474-7821
Mailing Address - Fax:
Practice Address - Street 1:34 WEST 27TH STREET
Practice Address - Street 2:SUITE 1212
Practice Address - City:NEW YORK CITY
Practice Address - State:NY
Practice Address - Zip Code:10001-2320
Practice Address - Country:US
Practice Address - Phone:917-474-7821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003825171100000X
NY008629225X00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171100000XOther Service ProvidersAcupuncturist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ0A141Medicare UPIN