Provider Demographics
NPI:1639986862
Name:MARRERA, MICHAEL (LMT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MARRERA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1146 WELLING CT APT 2R
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-4482
Mailing Address - Country:US
Mailing Address - Phone:347-231-6969
Mailing Address - Fax:
Practice Address - Street 1:2206 31ST ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-2714
Practice Address - Country:US
Practice Address - Phone:347-231-6969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030995-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist