Provider Demographics
NPI:1770831794
Name:BARDIN-DAVERSA, GAYLE R
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:R
Last Name:BARDIN-DAVERSA
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 1:10 RAYMOND CT
Mailing Address - Street 2:
Mailing Address - City:SEA CLIFF
Mailing Address - State:NY
Mailing Address - Zip Code:11579-2028
Mailing Address - Country:US
Mailing Address - Phone:516-676-0129
Mailing Address - Fax:516-676-6435
Practice Address - Street 1:10 RAYMOND CT
Practice Address - Street 2:
Practice Address - City:SEA CLIFF
Practice Address - State:NY
Practice Address - Zip Code:11579-2028
Practice Address - Country:US
Practice Address - Phone:516-676-0129
Practice Address - Fax:516-676-6435
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-23
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006787-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist