Provider Demographics
NPI:1528592367
Name:RADEVICH, ZHANNA
Entity Type:Individual
Prefix:MISS
First Name:ZHANNA
Middle Name:
Last Name:RADEVICH
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:ZHANNA
Other - Middle Name:
Other - Last Name:RADEVICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:172 PALISADE AVE
Mailing Address - Street 2:
Mailing Address - City:BOGOTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07603-1634
Mailing Address - Country:US
Mailing Address - Phone:201-820-4365
Mailing Address - Fax:201-820-4365
Practice Address - Street 1:172 PALISADE AVE
Practice Address - Street 2:
Practice Address - City:BOGOTA
Practice Address - State:NJ
Practice Address - Zip Code:07603
Practice Address - Country:US
Practice Address - Phone:201-880-5188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency