Provider Demographics
NPI:1922253566
Name:GUANZON, MICHELLE ANNE ENTOMA (PT)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE ANNE
Middle Name:ENTOMA
Last Name:GUANZON
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 1:21 MILL ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NY
Mailing Address - Zip Code:12754-2010
Mailing Address - Country:US
Mailing Address - Phone:845-292-8810
Mailing Address - Fax:845-292-8832
Practice Address - Street 1:21 MILL ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-2010
Practice Address - Country:US
Practice Address - Phone:845-292-8810
Practice Address - Fax:845-292-8832
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028729174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist