Provider Demographics
NPI:1053622803
Name:MEDVEDOVSKY, GABRIELLA (DPT)
Entity type:Individual
Prefix:MRS
First Name:GABRIELLA
Middle Name:
Last Name:MEDVEDOVSKY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:647 LAMOKA AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-3435
Mailing Address - Country:US
Mailing Address - Phone:718-226-9000
Mailing Address - Fax:
Practice Address - Street 1:375 SEGUINE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-3932
Practice Address - Country:US
Practice Address - Phone:718-226-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-27
Last Update Date:2010-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032033225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist