Provider Demographics
NPI:1154502177
Name:HAREWOOD, AVIS (NT)
Entity type:Individual
Prefix:
First Name:AVIS
Middle Name:
Last Name:HAREWOOD
Suffix:
Gender:F
Credentials:NT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 E 54TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-4646
Mailing Address - Country:US
Mailing Address - Phone:718-922-3944
Mailing Address - Fax:
Practice Address - Street 1:2534 STEINWAY ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-3702
Practice Address - Country:US
Practice Address - Phone:718-777-5243
Practice Address - Fax:718-777-5250
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004153-1133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist