Provider Demographics
NPI:1972157329
Name:GAVALYA, EMMA (LMT)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:
Last Name:GAVALYA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19543 PRIBILOF LOOP
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-8726
Mailing Address - Country:US
Mailing Address - Phone:907-575-9530
Mailing Address - Fax:
Practice Address - Street 1:10421 VFW RD STE 101
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-8075
Practice Address - Country:US
Practice Address - Phone:907-694-1285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK133090225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist