Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225XG0600X | Occupational Therapist - Gerontology | 021026 | NY |
Y | 225XP0200X | Occupational Therapist - Pediatrics | 021026 | NY |
NPI | 1255862199 |
---|---|
Provider Name | Jose Alex Arevalo |
First Address | Bethpage, NY 11714-2712 |
Second Address | Bethpage, NY 11714-2712 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/03/2017 |
Last Update Date | 22/03/2017 |