Provider Demographics
NPI:1740728633
Name:EVANGELISTA, LIVIA
Entity type:Individual
Prefix:
First Name:LIVIA
Middle Name:
Last Name:EVANGELISTA
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 1:110 GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-1238
Mailing Address - Country:US
Mailing Address - Phone:917-399-4121
Mailing Address - Fax:
Practice Address - Street 1:110 GEORGIA AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-1238
Practice Address - Country:US
Practice Address - Phone:917-399-4121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009050224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant