Provider Demographics
NPI:1558775114
Name:PENDLETON, EVA (LMT)
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:
Last Name:PENDLETON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4526 44TH ST APT 5F
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-2417
Mailing Address - Country:US
Mailing Address - Phone:646-325-3726
Mailing Address - Fax:
Practice Address - Street 1:4526 44TH ST APT 5F
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-2417
Practice Address - Country:US
Practice Address - Phone:646-325-3726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012204225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist