Provider Demographics
NPI:1730405903
Name:MARSHALL, DELVOURT CEYON (PTA)
Entity type:Individual
Prefix:
First Name:DELVOURT
Middle Name:CEYON
Last Name:MARSHALL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10906 108TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-1032
Mailing Address - Country:US
Mailing Address - Phone:813-312-5203
Mailing Address - Fax:
Practice Address - Street 1:475 PARK AVE S
Practice Address - Street 2:7TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6901
Practice Address - Country:US
Practice Address - Phone:212-683-1988
Practice Address - Fax:646-607-5965
Is Sole Proprietor?:No
Enumeration Date:2010-04-13
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0073781225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant