Provider Demographics
NPI:1104625086
Name:CANERO, MICHELLE ANNEVISAYA
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANNEVISAYA
Last Name:CANERO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:279 CLARK ST APT 16
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601
Mailing Address - Country:US
Mailing Address - Phone:352-316-0800
Mailing Address - Fax:
Practice Address - Street 1:25-21 49TH STREET
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103
Practice Address - Country:US
Practice Address - Phone:347-829-3890
Practice Address - Fax:347-829-3888
Is Sole Proprietor?:No
Enumeration Date:2025-03-12
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053527225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist