Provider Demographics
NPI:1275852063
Name:CUENCO, MA. IVY PAULINE CRISOSTOMO
Entity Type:Individual
Prefix:
First Name:MA. IVY PAULINE
Middle Name:CRISOSTOMO
Last Name:CUENCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 BERKMAN CIR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-6311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1126 BERKMAN CIR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-6311
Practice Address - Country:US
Practice Address - Phone:407-233-8302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017085225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist