Provider Demographics
NPI:1417210311
Name:BRUNNWASSER, MIRIAM LOIS (SPECIAL EDUCATOR)
Entity Type:Individual
Prefix:MS
First Name:MIRIAM
Middle Name:LOIS
Last Name:BRUNNWASSER
Suffix:
Gender:F
Credentials:SPECIAL EDUCATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9805 67TH AVE APT 4-0
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4969
Mailing Address - Country:US
Mailing Address - Phone:718-997-0880
Mailing Address - Fax:
Practice Address - Street 1:9805 67TH AVE
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4969
Practice Address - Country:US
Practice Address - Phone:718-997-0880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-17
Last Update Date:2012-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1516824174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY174400000XOtherEARLY INTERVENTION DEPARTMENT OF HEALTH