Provider Demographics
NPI:1003919614
Name:GOSS, ROBIN RENAE (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:ROBIN
Middle Name:RENAE
Last Name:GOSS
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 KLING TERRACE
Mailing Address - Street 2:
Mailing Address - City:VOORHEESVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12186-9545
Mailing Address - Country:US
Mailing Address - Phone:518-765-4351
Mailing Address - Fax:
Practice Address - Street 1:711 TROY SCHENECTADY RD
Practice Address - Street 2:THOMAS NICOLLA CONSULTING SUITE 209
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110
Practice Address - Country:US
Practice Address - Phone:518-786-1667
Practice Address - Fax:518-786-1954
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0038091225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03173131Medicaid