Provider Demographics
NPI:1689377293
Name:PAVLO, ANTHONY JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:JOHN
Last Name:PAVLO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4331 45TH ST APT 3J
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-2347
Mailing Address - Country:US
Mailing Address - Phone:347-871-1104
Mailing Address - Fax:
Practice Address - Street 1:4331 45TH ST APT 3J
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-2347
Practice Address - Country:US
Practice Address - Phone:347-871-1104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-23
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025509103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical