Provider Demographics
NPI:1215390174
Name:LIM, VIRGEN (PTA)
Entity Type:Individual
Prefix:
First Name:VIRGEN
Middle Name:
Last Name:LIM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6026 83RD PL
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379-5417
Mailing Address - Country:US
Mailing Address - Phone:845-321-3925
Mailing Address - Fax:
Practice Address - Street 1:6026 83RD PL
Practice Address - Street 2:2ND FLOOR
Practice Address - City:MIDDLE VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11379-5417
Practice Address - Country:US
Practice Address - Phone:845-321-3925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-29
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008478-1172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker