Provider Demographics
NPI:1740723410
Name:GOLDBLATT, ALISHA
Entity type:Individual
Prefix:
First Name:ALISHA
Middle Name:
Last Name:GOLDBLATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALISHA
Other - Middle Name:
Other - Last Name:SUMMERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2601 MOTT AVE
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-1761
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2601 MOTT AVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-1761
Practice Address - Country:US
Practice Address - Phone:718-327-1910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016316-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist