Healthcare Provider Details

I. General information

NPI: 1790798890
Provider Name (Legal Business Name): NANDA J NEVOLA PT PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 08/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 LAKE RD
VALLEY COTTAGE NY
10989-2339
US

IV. Provider business mailing address

104 LAKE RD
VALLEY COTTAGE NY
10989-2339
US

V. Phone/Fax

Practice location:
  • Phone: 845-300-2847
  • Fax: 866-841-2452
Mailing address:
  • Phone: 845-300-2847
  • Fax: 866-841-2452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number015158
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. NANDA J NEVOLA
Title or Position: PRESIDENT
Credential: PT
Phone: 453-002-8478