Provider Demographics
NPI:1457121543
Name:BERESFORD, TREVANIA
Entity Type:Individual
Prefix:
First Name:TREVANIA
Middle Name:
Last Name:BERESFORD
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 1:1100 OCEAN AVE APT 3B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-1936
Mailing Address - Country:US
Mailing Address - Phone:347-334-2337
Mailing Address - Fax:
Practice Address - Street 1:107 W 82ND ST STE 108
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-5511
Practice Address - Country:US
Practice Address - Phone:917-558-0228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032856225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist