Provider Demographics
NPI:1023175007
Name:MARCELLINO-RILEY, CYNTHIA (PT)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:MARCELLINO-RILEY
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 1:42 COALTER RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:DARDENNE PRAIRIE
Mailing Address - State:MO
Mailing Address - Zip Code:63368-7587
Mailing Address - Country:US
Mailing Address - Phone:314-753-4822
Mailing Address - Fax:
Practice Address - Street 1:42 COALTER RIDGE CT
Practice Address - Street 2:
Practice Address - City:DARDENNE PRAIRIE
Practice Address - State:MO
Practice Address - Zip Code:63368-7587
Practice Address - Country:US
Practice Address - Phone:314-753-4822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MO20020195832251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO485917017Medicaid