Provider Demographics
NPI:1790375186
Name:DESRIVIERES, MARIE RENEE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:RENEE
Last Name:DESRIVIERES
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 1:643 EMPIRE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-2810
Mailing Address - Country:US
Mailing Address - Phone:347-526-0765
Mailing Address - Fax:
Practice Address - Street 1:800 E GATE BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-2105
Practice Address - Country:US
Practice Address - Phone:516-745-8050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032576225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist