Provider Demographics
NPI:1922506534
Name:EARL, TONETTE (SERVICE COORDINATOR)
Entity Type:Individual
Prefix:
First Name:TONETTE
Middle Name:
Last Name:EARL
Suffix:
Gender:F
Credentials:SERVICE COORDINATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 WILLIAMS AVE
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10977-3005
Mailing Address - Country:US
Mailing Address - Phone:917-741-8586
Mailing Address - Fax:
Practice Address - Street 1:3140B E TREMONT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-5706
Practice Address - Country:US
Practice Address - Phone:718-239-4147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY252Y00000XOtherEARLY INTERVENTION PROVIDER
NY25Y00000XMedicaid