Provider Demographics
NPI:1699058115
Name:CHETAN, DIVYA
Entity type:Individual
Prefix:MS
First Name:DIVYA
Middle Name:
Last Name:CHETAN
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 1:280 MARIN BLVD
Mailing Address - Street 2:APT 14K
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-3654
Mailing Address - Country:US
Mailing Address - Phone:201-710-7035
Mailing Address - Fax:
Practice Address - Street 1:1428 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3908
Practice Address - Country:US
Practice Address - Phone:718-698-3055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2012-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033795225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist