Provider Demographics
NPI:1306204839
Name:PANGANIBAN, AVE GAY
Entity Type:Individual
Prefix:
First Name:AVE GAY
Middle Name:
Last Name:PANGANIBAN
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 1:15874 NE 10TH CT
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-5350
Mailing Address - Country:US
Mailing Address - Phone:305-934-6122
Mailing Address - Fax:
Practice Address - Street 1:333 E ONTARIO ST
Practice Address - Street 2:UNIT 801
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4804
Practice Address - Country:US
Practice Address - Phone:305-934-6122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056011362225X00000X
FLOT16470225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist