Provider Demographics
NPI:1407096936
Name:GOLDWAG, SHOSHANA BRACHA (OTR)
Entity Type:Individual
Prefix:MS
First Name:SHOSHANA
Middle Name:BRACHA
Last Name:GOLDWAG
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 BEDELL TER
Mailing Address - Street 2:
Mailing Address - City:WEST HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11552-2444
Mailing Address - Country:US
Mailing Address - Phone:516-538-8536
Mailing Address - Fax:
Practice Address - Street 1:255 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-1718
Practice Address - Country:US
Practice Address - Phone:516-576-2040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-24
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0144861252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency