Provider Demographics
NPI:1649752411
Name:BEREZA, MARINA
Entity Type:Individual
Prefix:MS
First Name:MARINA
Middle Name:
Last Name:BEREZA
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 1:92 ASHWOOD RD
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-1620
Mailing Address - Country:US
Mailing Address - Phone:646-725-7309
Mailing Address - Fax:
Practice Address - Street 1:92 ASHWOOD RD
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-1620
Practice Address - Country:US
Practice Address - Phone:646-725-7309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0083531225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant