Provider Demographics
NPI:1215273214
Name:CANELOS, MARLENE Y, (OTA)
Entity type:Individual
Prefix:MISS
First Name:MARLENE
Middle Name:Y,
Last Name:CANELOS
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7217 48TH AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-6012
Mailing Address - Country:US
Mailing Address - Phone:718-476-1959
Mailing Address - Fax:
Practice Address - Street 1:7217 48TH AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-6012
Practice Address - Country:US
Practice Address - Phone:718-476-1959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008212-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY224Z00000XOtherTAXONOMY