Basic Information
| Provider Information | |||||||||
| NPI: | 1487198198 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | SEVERINA | ||||||||
| FirstName: | GANNA | ||||||||
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| Credential: | COTA/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2299 E 13TH ST | ||||||||
| Address2: | APT 3A | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112294329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466234838 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4915 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112193301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188513700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2016 | ||||||||
| LastUpdateDate: | 12/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 009172 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.