Provider Demographics
NPI:1932277704
Name:MAGBANUA, RUSSALETTE ORTIZ (MPS, OTRL)
Entity type:Individual
Prefix:MS
First Name:RUSSALETTE
Middle Name:ORTIZ
Last Name:MAGBANUA
Suffix:
Gender:F
Credentials:MPS, OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7261 113TH ST
Mailing Address - Street 2:APT 3P
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-5635
Mailing Address - Country:US
Mailing Address - Phone:917-459-3695
Mailing Address - Fax:
Practice Address - Street 1:180 W END AVE
Practice Address - Street 2:#1M
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-4902
Practice Address - Country:US
Practice Address - Phone:212-600-4871
Practice Address - Fax:800-655-3780
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010144225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist