Provider Demographics
NPI:1215995303
Name:PANTANELLA, THERESA RENE (OT/L, MPA, OTD)
Entity type:Individual
Prefix:DR
First Name:THERESA
Middle Name:RENE
Last Name:PANTANELLA
Suffix:
Gender:F
Credentials:OT/L, MPA, OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 SE 5TH CT
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33060-8465
Mailing Address - Country:US
Mailing Address - Phone:954-785-8229
Mailing Address - Fax:954-785-9227
Practice Address - Street 1:3221 NW 10TH TER
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-5942
Practice Address - Country:US
Practice Address - Phone:954-785-8229
Practice Address - Fax:954-785-9227
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0002000225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ6542ZMedicare ID - Type UnspecifiedPROVIDER