Provider Demographics
NPI:1922248707
Name:MORCILLA, CHARMAINE (PT)
Entity Type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:
Last Name:MORCILLA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 30TH AVE APT 5H
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-2413
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2536 27TH ST
Practice Address - Street 2:1A
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-2308
Practice Address - Country:US
Practice Address - Phone:347-208-4511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-06
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY28547225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist