Healthcare Provider Details

I. General information

NPI: 1114523180
Provider Name (Legal Business Name): MS. JEANNETT LLAVE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 NORTHERN BLVD
GREAT NECK NY
11021-4819
US

IV. Provider business mailing address

9906 58TH AVE APT 1H
CORONA NY
11368-3701
US

V. Phone/Fax

Practice location:
  • Phone: 718-650-6230
  • Fax:
Mailing address:
  • Phone: 347-935-7189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number025127
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: