Provider Demographics
NPI:1538827886
Name:LIAO, IVANA
Entity type:Individual
Prefix:
First Name:IVANA
Middle Name:
Last Name:LIAO
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 1:100 MONTICELLO TER
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-2836
Mailing Address - Country:US
Mailing Address - Phone:718-909-3323
Mailing Address - Fax:855-955-3899
Practice Address - Street 1:8415 4TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-4654
Practice Address - Country:US
Practice Address - Phone:718-648-0888
Practice Address - Fax:855-955-3899
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
NY048042225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty