Provider Demographics
NPI:1790170314
Name:SEPULVEDA, THELMA
Entity Type:Individual
Prefix:
First Name:THELMA
Middle Name:
Last Name:SEPULVEDA
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 1:452 BIRCH DR
Mailing Address - Street 2:
Mailing Address - City:CRESCO
Mailing Address - State:PA
Mailing Address - Zip Code:18326-7762
Mailing Address - Country:US
Mailing Address - Phone:917-523-3312
Mailing Address - Fax:
Practice Address - Street 1:452 BIRCH DR
Practice Address - Street 2:
Practice Address - City:CRESCO
Practice Address - State:PA
Practice Address - Zip Code:18326-7762
Practice Address - Country:US
Practice Address - Phone:917-523-3312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-31
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC013781225X00000X
NY004858225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist