Provider Demographics
NPI:1760592117
Name:GLORIA, EDELWINA ANCANAN (PT)
Entity Type:Individual
Prefix:MRS
First Name:EDELWINA
Middle Name:ANCANAN
Last Name:GLORIA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:EDELWINA
Other - Middle Name:GUEVARRA
Other - Last Name:ANCANAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3709 62ND ST
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-2622
Mailing Address - Country:US
Mailing Address - Phone:718-639-5145
Mailing Address - Fax:
Practice Address - Street 1:227 MADISON ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-7537
Practice Address - Country:US
Practice Address - Phone:212-238-7680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024183225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist