Provider Demographics
NPI:1508215641
Name:PERVIZI, CARMELLA
Entity Type:Individual
Prefix:
First Name:CARMELLA
Middle Name:
Last Name:PERVIZI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3666 OLD YORKTOWN RD
Mailing Address - Street 2:
Mailing Address - City:SHRUB OAK
Mailing Address - State:NY
Mailing Address - Zip Code:10588-1502
Mailing Address - Country:US
Mailing Address - Phone:347-821-6385
Mailing Address - Fax:
Practice Address - Street 1:3666 OLD YORKTOWN RD
Practice Address - Street 2:
Practice Address - City:SHRUB OAK
Practice Address - State:NY
Practice Address - Zip Code:10588-1502
Practice Address - Country:US
Practice Address - Phone:347-821-6385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY584756051171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator