Provider Demographics
NPI:1578254199
Name:NISANOV, RUTH (OT)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:NISANOV
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6308 69TH PL
Mailing Address - Street 2:
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379-1726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6308 69TH PL
Practice Address - Street 2:
Practice Address - City:MIDDLE VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11379-1726
Practice Address - Country:US
Practice Address - Phone:718-381-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027910225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist