Provider Demographics
NPI:1851912448
Name:D'AVERSA, TATYANA (ATC,MPH)
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:D'AVERSA
Suffix:
Gender:F
Credentials:ATC,MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 YORK AVE APT 13R
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4856
Mailing Address - Country:US
Mailing Address - Phone:631-662-0040
Mailing Address - Fax:
Practice Address - Street 1:1320 YORK AVE APT 13R
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4856
Practice Address - Country:US
Practice Address - Phone:631-662-0040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01235772255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer