MEDICARE: MRS. ZANNELLE TAVERAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist
2	103TS0200X	School Psychologist		NY

General Provider Information

NPI Number	:	1598118671
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ZANNELLE TAVERAS

Provider Business Mailing Address
First Line	:	1400 OLD COUNTRY RD STE C103N
Second Line	:
City	:	WESTBURY
State	:	NY
Zip	:	11590-5156
Country	:	US
Telephone Number	:	917-655-5413
Fax Number	:

Provider Business Practice Location Address
First Line	:	2122 LAFAYETTE AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10473-1314
Country	:	US
Telephone Number	:	917-655-5413
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2016
Last Update Date	:	02/26/2025

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