Provider Demographics
NPI:1487051496
Name:MARISCAL, CLEOFE (PT)
Entity type:Individual
Prefix:
First Name:CLEOFE
Middle Name:
Last Name:MARISCAL
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 1:110 ST NICHOLAS AVENUE 1R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237
Mailing Address - Country:US
Mailing Address - Phone:347-564-9906
Mailing Address - Fax:
Practice Address - Street 1:110 SAINT NICHOLAS AVE
Practice Address - Street 2:1R
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-3440
Practice Address - Country:US
Practice Address - Phone:347-564-9906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-20
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019266225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist