Provider Demographics
NPI:1447905211
Name:ZELAYA, EARL TEVIN III
Entity type:Individual
Prefix:
First Name:EARL
Middle Name:TEVIN
Last Name:ZELAYA
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 ARDMORE DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-2338
Mailing Address - Country:US
Mailing Address - Phone:631-383-0522
Mailing Address - Fax:
Practice Address - Street 1:6 ARDMORE DR
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-2338
Practice Address - Country:US
Practice Address - Phone:631-383-0522
Practice Address - Fax:631-383-0522
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-19
Last Update Date:2022-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
123OtherJ&A BEHAVIORAL