Provider Demographics
NPI:1629837661
Name:DEROVANESSIAN, THERESE
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:DEROVANESSIAN
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 1:230 W 125TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-4402
Mailing Address - Country:US
Mailing Address - Phone:646-981-4504
Mailing Address - Fax:
Practice Address - Street 1:230 W 125TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-4402
Practice Address - Country:US
Practice Address - Phone:646-981-4504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-13
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program