Healthcare Provider Details

I. General information

NPI: 1881051639
Provider Name (Legal Business Name): VINU DEVASIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2016
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1419 SHAKESPEARE AVE
BRONX NY
10452-1851
US

IV. Provider business mailing address

18 GLEN HAVEN DR
NEW CITY NY
10956-5837
US

V. Phone/Fax

Practice location:
  • Phone: 718-732-7080
  • Fax: 718-732-7090
Mailing address:
  • Phone: 845-708-5698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number096573
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: