Provider Demographics
NPI:1316617244
Name:VALLADARES, ANTONIO (LMT)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:VALLADARES
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 TAAFFE PL APT 4R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205-4383
Mailing Address - Country:US
Mailing Address - Phone:917-202-9838
Mailing Address - Fax:
Practice Address - Street 1:209 TAAFFE PL APT 4R
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11205-4383
Practice Address - Country:US
Practice Address - Phone:917-202-9838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009583225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist