Provider Demographics
NPI:1619928314
Name:SERRANO, CYNTHIA JEAN (OT)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:JEAN
Last Name:SERRANO
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 W COUNTRY CLUB RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-0618
Mailing Address - Country:US
Mailing Address - Phone:505-623-2292
Mailing Address - Fax:505-623-2255
Practice Address - Street 1:110 W COUNTRY CLUB RD
Practice Address - Street 2:SUITE 3
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-0618
Practice Address - Country:US
Practice Address - Phone:505-623-2292
Practice Address - Fax:505-623-2255
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM295225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM31353282Medicaid