Provider Demographics
NPI:1760635932
Name:TAN, MAYBELLINE
Entity Type:Individual
Prefix:
First Name:MAYBELLINE
Middle Name:
Last Name:TAN
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 1:300 LIVINGSTON AVE
Mailing Address - Street 2:APT. 2J
Mailing Address - City:MAMARONECK
Mailing Address - State:NY
Mailing Address - Zip Code:10543-3500
Mailing Address - Country:US
Mailing Address - Phone:917-453-2508
Mailing Address - Fax:
Practice Address - Street 1:300 LIVINGSTON AVE
Practice Address - Street 2:APT. 2J
Practice Address - City:MAMARONECK
Practice Address - State:NY
Practice Address - Zip Code:10543-3500
Practice Address - Country:US
Practice Address - Phone:917-453-2508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009479-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics