Healthcare Provider Details

I. General information

NPI: 1235635244
Provider Name (Legal Business Name): VIVA WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2018
Last Update Date: 03/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 MONTAGUE ST
BROOKLYN NY
11201-3628
US

IV. Provider business mailing address

114 W 81ST ST APT GF
NEW YORK NY
10024-5928
US

V. Phone/Fax

Practice location:
  • Phone: 646-598-9955
  • Fax:
Mailing address:
  • Phone: 917-838-9803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number005426
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: RACHEL GERSTEN
Title or Position: CO-OWNER
Credential: LMHC
Phone: 917-838-9803