Provider Demographics
NPI:1346797958
Name:KNICKMAN, ROBERT L
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:KNICKMAN
Suffix:
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 1:14312 OAK AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-2312
Mailing Address - Country:US
Mailing Address - Phone:516-816-1381
Mailing Address - Fax:
Practice Address - Street 1:14312 OAK AVE
Practice Address - Street 2:APT 2
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-2312
Practice Address - Country:US
Practice Address - Phone:516-816-1381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00197800225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist