Provider Demographics
NPI:1467112912
Name:TENERELLI, MICHAEL DOMENICK (LMT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DOMENICK
Last Name:TENERELLI
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 1:10 CORTEZ LN
Mailing Address - Street 2:
Mailing Address - City:KINGS PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11754-4518
Mailing Address - Country:US
Mailing Address - Phone:631-379-3159
Mailing Address - Fax:
Practice Address - Street 1:10 CORTEZ LN
Practice Address - Street 2:
Practice Address - City:KINGS PARK
Practice Address - State:NY
Practice Address - Zip Code:11754-4518
Practice Address - Country:US
Practice Address - Phone:631-379-3159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-26
Last Update Date:2021-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032715-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty