Provider Demographics
NPI:1801234372
Name:GERVASIO, CARLA (LAC)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:GERVASIO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 E 73RD ST
Mailing Address - Street 2:SUITE GR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-3519
Mailing Address - Country:US
Mailing Address - Phone:212-603-9133
Mailing Address - Fax:
Practice Address - Street 1:55 E 73RD ST
Practice Address - Street 2:SUITE GR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-3519
Practice Address - Country:US
Practice Address - Phone:212-603-9133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005086171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist