Provider Demographics
NPI:1063934370
Name:BAVERO, THERESA (MA, LCAT, CT)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:BAVERO
Suffix:
Gender:F
Credentials:MA, LCAT, CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3255 48TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-1432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:928 BROADWAY STE 400
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-8149
Practice Address - Country:US
Practice Address - Phone:914-584-4167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-10
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001998101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health