Healthcare Provider Details

I. General information

NPI: 1447521216
Provider Name (Legal Business Name): GINA MARIE MONTALVO LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 10/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 PINE RIDGE LN
ACCORD NY
12404-5753
US

IV. Provider business mailing address

28 PINE RIDGE LN
ACCORD NY
12404-5753
US

V. Phone/Fax

Practice location:
  • Phone: 914-388-9694
  • Fax:
Mailing address:
  • Phone: 914-388-9694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number023410-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: