Provider Demographics
NPI:1760817696
Name:TEBANO, MICHELA GIOVANNA (LAC)
Entity Type:Individual
Prefix:
First Name:MICHELA
Middle Name:GIOVANNA
Last Name:TEBANO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 W 23RD ST
Mailing Address - Street 2:PH4PS
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-1144
Mailing Address - Country:US
Mailing Address - Phone:845-674-7632
Mailing Address - Fax:
Practice Address - Street 1:535 W 23RD ST
Practice Address - Street 2:PH4PS
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-1144
Practice Address - Country:US
Practice Address - Phone:845-674-7632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
25 005135171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist