Provider Demographics
NPI:1992522486
Name:REVELLO, LEAH J
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:J
Last Name:REVELLO
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 1:68 S SERVICE RD
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-2354
Mailing Address - Country:US
Mailing Address - Phone:631-600-3029
Mailing Address - Fax:
Practice Address - Street 1:208 FLORAL PKWY
Practice Address - Street 2:
Practice Address - City:SOUTH FLORAL PARK
Practice Address - State:NY
Practice Address - Zip Code:11001-3439
Practice Address - Country:US
Practice Address - Phone:646-472-4963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029239225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics