Provider Demographics
NPI:1396989877
Name:REVAMUNTAN, MATHERESA (PT)
Entity type:Individual
Prefix:
First Name:MATHERESA
Middle Name:
Last Name:REVAMUNTAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6315 ALDERTON ST
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2824
Mailing Address - Country:US
Mailing Address - Phone:917-226-8075
Mailing Address - Fax:
Practice Address - Street 1:2273 65TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-4086
Practice Address - Country:US
Practice Address - Phone:718-236-4970
Practice Address - Fax:718-621-9302
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist