Provider Demographics
NPI:1386264224
Name:SEVILLA, MYRTZ MELODY REVESENCIO
Entity type:Individual
Prefix:
First Name:MYRTZ MELODY
Middle Name:REVESENCIO
Last Name:SEVILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 BEACH 99TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694-2807
Mailing Address - Country:US
Mailing Address - Phone:916-513-3907
Mailing Address - Fax:
Practice Address - Street 1:160 BEACH 99TH ST
Practice Address - Street 2:
Practice Address - City:ROCKAWAY PARK
Practice Address - State:NY
Practice Address - Zip Code:11694-2807
Practice Address - Country:US
Practice Address - Phone:916-513-3907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA246922251H1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHandGroup - Multi-Specialty