Provider Demographics
NPI:1104953009
Name:BEREAN, NELLY T
Entity type:Individual
Prefix:
First Name:NELLY
Middle Name:T
Last Name:BEREAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NELLY
Other - Middle Name:T
Other - Last Name:BEREAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA
Mailing Address - Street 1:11 FAYE AVE
Mailing Address - Street 2:
Mailing Address - City:NEW WINDSOR
Mailing Address - State:NY
Mailing Address - Zip Code:12553-7709
Mailing Address - Country:US
Mailing Address - Phone:845-568-5734
Mailing Address - Fax:
Practice Address - Street 1:11 FAYE AVE
Practice Address - Street 2:
Practice Address - City:NEW WINDSOR
Practice Address - State:NY
Practice Address - Zip Code:12553-7709
Practice Address - Country:US
Practice Address - Phone:845-568-5734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003757174400000X, 224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered174400000XOther Service ProvidersSpecialist
Not Answered224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant