Healthcare Provider Details

I. General information

NPI: 1700511987
Provider Name (Legal Business Name): PETAGAYE BRYAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2022
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2175 WESTCHESTER AVE
BRONX NY
10462-4734
US

IV. Provider business mailing address

2175 WESTCHESTER AVE
BRONX NY
10462-4734
US

V. Phone/Fax

Practice location:
  • Phone: 718-829-6777
  • Fax:
Mailing address:
  • Phone: 718-829-6770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number119209
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: