Provider Demographics
NPI:1841731312
Name:CREVISON, MARIANA (ATC)
Entity type:Individual
Prefix:
First Name:MARIANA
Middle Name:
Last Name:CREVISON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14546-1153
Mailing Address - Country:US
Mailing Address - Phone:585-794-1805
Mailing Address - Fax:
Practice Address - Street 1:20 CEDAR ST
Practice Address - Street 2:
Practice Address - City:SCOTTSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14546-1153
Practice Address - Country:US
Practice Address - Phone:585-794-1805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20000304102255A2300X
NY2255A2300X390200000X
NY0035942255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program