Provider Demographics
NPI:1821796822
Name:GAVIGAN, YOLANDA (LAC, LMT)
Entity Type:Individual
Prefix:
First Name:YOLANDA
Middle Name:
Last Name:GAVIGAN
Suffix:
Gender:F
Credentials:LAC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 HASTINGS DR
Mailing Address - Street 2:
Mailing Address - City:FORT SALONGA
Mailing Address - State:NY
Mailing Address - Zip Code:11768-2509
Mailing Address - Country:US
Mailing Address - Phone:516-252-8098
Mailing Address - Fax:
Practice Address - Street 1:24 BELLEMEADE AVE STE B
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-1855
Practice Address - Country:US
Practice Address - Phone:845-827-3637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007368171100000X
NY030453225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171100000XOther Service ProvidersAcupuncturist