Provider Demographics
NPI:1629236278
Name:EBORA FERNANDO, MARIEVIC BALAAG (PT, DPT)
Entity Type:Individual
Prefix:MS
First Name:MARIEVIC
Middle Name:BALAAG
Last Name:EBORA FERNANDO
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MARIEVIC
Other - Middle Name:EBORA
Other - Last Name:VILLANUEVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:6815 SELFRIDGE ST
Mailing Address - Street 2:2H
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-5747
Mailing Address - Country:US
Mailing Address - Phone:347-777-9707
Mailing Address - Fax:
Practice Address - Street 1:6815 SELFRIDGE ST
Practice Address - Street 2:2H
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-5747
Practice Address - Country:US
Practice Address - Phone:347-777-9707
Practice Address - Fax:347-777-9707
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030067225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist