Provider Demographics
NPI:1124467287
Name:FAMANILA, JANOVLY JEREMIAH GANA (OTR)
Entity type:Individual
Prefix:
First Name:JANOVLY JEREMIAH
Middle Name:GANA
Last Name:FAMANILA
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 HOBART AVE APT 10D
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-4173
Mailing Address - Country:US
Mailing Address - Phone:646-331-2040
Mailing Address - Fax:
Practice Address - Street 1:3636 33RD ST STE 500
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11106-2329
Practice Address - Country:US
Practice Address - Phone:212-529-9780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017383225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist