Provider Demographics
NPI:1942062195
Name:CANO, ELSIE REBECCA (ITDS)
Entity Type:Individual
Prefix:MRS
First Name:ELSIE
Middle Name:REBECCA
Last Name:CANO
Suffix:
Gender:F
Credentials:ITDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4031 SW BAMBERG ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-7030
Mailing Address - Country:US
Mailing Address - Phone:772-293-1661
Mailing Address - Fax:
Practice Address - Street 1:4031 SW BAMBERG ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-7030
Practice Address - Country:US
Practice Address - Phone:772-293-1661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist