Provider Demographics
NPI:1700437860
Name:MOGAVERO, KERRY
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:MOGAVERO
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 1:2 LOTUS LN
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-6321
Mailing Address - Country:US
Mailing Address - Phone:516-996-0704
Mailing Address - Fax:516-377-2098
Practice Address - Street 1:380 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:NY
Practice Address - Zip Code:11575-1845
Practice Address - Country:US
Practice Address - Phone:516-378-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-20
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0054791225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant