Provider Demographics
NPI:1588027221
Name:AVEZOVA, EMA
Entity Type:Individual
Prefix:
First Name:EMA
Middle Name:
Last Name:AVEZOVA
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 1:6393 WOODHAVEN BLVD
Mailing Address - Street 2:APT#4C
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4843
Mailing Address - Country:US
Mailing Address - Phone:917-693-8465
Mailing Address - Fax:
Practice Address - Street 1:6393 WOODHAVEN BLVD
Practice Address - Street 2:APT#4C
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4843
Practice Address - Country:US
Practice Address - Phone:917-693-8465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019688225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist