Provider Demographics
NPI:1578080800
Name:SARESA, INDUBEN P
Entity Type:Individual
Prefix:
First Name:INDUBEN
Middle Name:P
Last Name:SARESA
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 1:1274 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-7450
Mailing Address - Country:US
Mailing Address - Phone:646-820-5669
Mailing Address - Fax:646-368-8339
Practice Address - Street 1:1274 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-7450
Practice Address - Country:US
Practice Address - Phone:646-820-5669
Practice Address - Fax:646-820-5669
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9551147225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant