Basic Information
Provider Information
NPI: 1033559406
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: AVERSO
FirstName: ERIKA
MiddleName: MARIA
NamePrefix: MRS.
NameSuffix:  
Credential: MS/TSHH
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 87 LYON ST
Address2:  
City: VALLEY STREAM
State: NY
PostalCode: 115803517
CountryCode: US
TelephoneNumber: 5169217171
FaxNumber:  
Practice Location
Address1: 47 HUMPHREY DR
Address2:  
City: SYOSSET
State: NY
PostalCode: 117914022
CountryCode: US
TelephoneNumber: 5169217171
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/01/2013
LastUpdateDate: 07/01/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
174400000X NYY Other Service ProvidersSpecialist 

No ID Information.


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