Provider Demographics
NPI:1588819866
Name:KISS, REVA ELANA (MS OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:REVA
Middle Name:ELANA
Last Name:KISS
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:ELANA
Other - Last Name:BOLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1373 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-6103
Mailing Address - Country:US
Mailing Address - Phone:718-645-3828
Mailing Address - Fax:
Practice Address - Street 1:1373 E 19TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-6103
Practice Address - Country:US
Practice Address - Phone:718-645-3828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-30
Last Update Date:2008-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011184-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist