Provider Demographics
NPI:1881834810
Name:GOLDIS WACHSTOCK, MIRA (MA, OTR/L)
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:GOLDIS WACHSTOCK
Suffix:
Gender:F
Credentials:MA, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19614 POMPEII AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-1418
Mailing Address - Country:US
Mailing Address - Phone:718-464-0709
Mailing Address - Fax:
Practice Address - Street 1:19614 POMPEII AVE
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-1418
Practice Address - Country:US
Practice Address - Phone:718-464-0709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-04
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010633-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics