Basic Information
| Provider Information | |||||||||
| NPI: | 1003299017 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THELEN-CLEMMONS | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | AVILA | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 88 MESEROLE AVE APT 2D | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112222675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067692098 | ||||||||
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| Practice Location | |||||||||
| Address1: | 88 MESEROLE AVE APT 2D | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112222675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067692098 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2015 | ||||||||
| LastUpdateDate: | 07/08/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X | 0197491 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
No ID Information.