Basic Information
| Provider Information | |||||||||
| NPI: | 1215576293 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FEVELO | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 307 5TH AVE FL 6 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100166575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127592282 | ||||||||
| FaxNumber: | 2123792123 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 BROAD ST # STREETA | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100042304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6467907454 | ||||||||
| FaxNumber: | 2123792076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2019 | ||||||||
| LastUpdateDate: | 07/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 040.0134120 | VT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 10470R | LA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 044865 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.