Provider Demographics
NPI:1396488672
Name:JAYASREE RAVEENDRAN, DHANYA (PT)
Entity type:Individual
Prefix:
First Name:DHANYA
Middle Name:
Last Name:JAYASREE RAVEENDRAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9522 63RD ROAD
Mailing Address - Street 2:SUITE 412
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374
Mailing Address - Country:US
Mailing Address - Phone:718-618-0052
Mailing Address - Fax:718-534-4135
Practice Address - Street 1:1975 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453
Practice Address - Country:US
Practice Address - Phone:718-618-0052
Practice Address - Fax:718-534-4135
Is Sole Proprietor?:No
Enumeration Date:2022-04-15
Last Update Date:2023-02-23
Deactivation Date:2023-01-12
Deactivation Code:
Reactivation Date:2023-02-13
Provider Licenses
StateLicense IDTaxonomies
NY047940-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY047940-01OtherSTATE LICENSE