Provider Demographics
NPI:1750103032
Name:ECHEVERRY, EDNA VIVIANA (LMT)
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:VIVIANA
Last Name:ECHEVERRY
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 1:19 COOLIDGE PL
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07506-2601
Mailing Address - Country:US
Mailing Address - Phone:201-613-3863
Mailing Address - Fax:
Practice Address - Street 1:297 KINDERKAMACK RD STE 206
Practice Address - Street 2:
Practice Address - City:ORADELL
Practice Address - State:NJ
Practice Address - Zip Code:07649-1535
Practice Address - Country:US
Practice Address - Phone:201-613-3863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00716700225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist