Provider Demographics
NPI:1689800476
Name:FRUCHTER, MIRIAM (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:
Last Name:FRUCHTER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MS
Other - First Name:MIRIAM
Other - Middle Name:
Other - Last Name:MOSKOWITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:6991 136TH ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1909
Mailing Address - Country:US
Mailing Address - Phone:917-376-8479
Mailing Address - Fax:
Practice Address - Street 1:6991 136TH ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-1909
Practice Address - Country:US
Practice Address - Phone:917-376-8479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-07
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014897235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03798923Medicaid