Provider Demographics
NPI:1336976133
Name:SEPULVEDA, RAQUEL
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:SEPULVEDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RAQUEL
Other - Middle Name:
Other - Last Name:SEPULVEDA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA (DHH), SPED ED,
Mailing Address - Street 1:151 PLEASANT VIEW RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:12569-7219
Mailing Address - Country:US
Mailing Address - Phone:347-251-8948
Mailing Address - Fax:
Practice Address - Street 1:151 PLEASANT VIEW RD
Practice Address - Street 2:
Practice Address - City:PLEASANT VALLEY
Practice Address - State:NY
Practice Address - Zip Code:12569-7219
Practice Address - Country:US
Practice Address - Phone:347-251-8948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY634567051174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty