Basic Information
Provider Information
NPI: 1003142746
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LIBO-ON
FirstName: MARY TSREVICH
MiddleName: ESTORES
NamePrefix: MISS
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: LIBO-ON
OtherFirstName: MARY
OtherMiddleName: TSAREVICH
OtherNamePrefix: MISS
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType: 5
Mailing Information
Address1: 6953 185TH ST
Address2:  
City: FRESH MEADOWS
State: NY
PostalCode: 113653513
CountryCode: US
TelephoneNumber: 6462670502
FaxNumber:  
Practice Location
Address1: 6953 185TH ST
Address2:  
City: FRESH MEADOWS
State: NY
PostalCode: 113653513
CountryCode: US
TelephoneNumber: 6462670502
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/31/2009
LastUpdateDate: 10/31/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X40QA01077600NJY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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