Provider Demographics
NPI:1538874904
Name:LAVILETTE, JILL (LMT)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:LAVILETTE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 BEACH 97TH ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11693-1308
Mailing Address - Country:US
Mailing Address - Phone:646-591-9040
Mailing Address - Fax:
Practice Address - Street 1:215 BEACH 97TH ST UNIT 2
Practice Address - Street 2:
Practice Address - City:ROCKAWAY BEACH
Practice Address - State:NY
Practice Address - Zip Code:11693-1308
Practice Address - Country:US
Practice Address - Phone:646-591-9040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020755225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist