MEDICARE: LIVIA EVANGELISTA

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	224Z00000X	Occupational Therapy Assistant	009050	NY

General Provider Information

NPI Number	:	1740728633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIVIA EVANGELISTA

Provider Business Mailing Address
First Line	:	110 GEORGIA AVE
Second Line	:
City	:	LONG BEACH
State	:	NY
Zip	:	11561-1238
Country	:	US
Telephone Number	:	917-399-4121
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 GEORGIA AVE
Second Line	:
City	:	LONG BEACH
State	:	NY
Zip	:	11561-1238
Country	:	US
Telephone Number	:	917-399-4121
Fax Number	:

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

Provider Enumeration Date	:	02/10/2017
Last Update Date	:	02/10/2017

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Directions to “ LIVIA EVANGELISTA ” Practice Location

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