Provider Demographics
NPI:1609521483
Name:MILLEVO, MARIE LOUISE TIOSAN (PT)
Entity type:Individual
Prefix:
First Name:MARIE LOUISE
Middle Name:TIOSAN
Last Name:MILLEVO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 MAIN ST APT 740
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10044-0171
Mailing Address - Country:US
Mailing Address - Phone:201-682-1038
Mailing Address - Fax:
Practice Address - Street 1:2678 KINGSBRIDGE TER
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-7471
Practice Address - Country:US
Practice Address - Phone:718-796-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-19
Last Update Date:2022-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045845225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
045845OtherLICENSE