Provider Demographics
NPI:1659985299
Name:GOSTEV, TATIANA V (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:V
Last Name:GOSTEV
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13-02 FAIR LAWN AVE
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-2229
Mailing Address - Country:US
Mailing Address - Phone:917-517-9783
Mailing Address - Fax:
Practice Address - Street 1:13-02 FAIR LAWN AVE
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-2229
Practice Address - Country:US
Practice Address - Phone:917-517-9783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026383225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty