Basic Information
| Provider Information | |||||||||
| NPI: | 1538756317 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVANI | ||||||||
| FirstName: | ELISA | ||||||||
| MiddleName: | |||||||||
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| Credential: | ED. M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6418 MADISON ST APT 3L | ||||||||
| Address2: | |||||||||
| City: | RIDGEWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113854606 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1651 CONEY ISLAND AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112305849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189981415 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2020 | ||||||||
| LastUpdateDate: | 12/28/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | NY | Y | Other Service Providers | Specialist |
No ID Information.