Provider Demographics
NPI:1184172710
Name:GOOSBY, ERICA (OTA)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:GOOSBY
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3619 BOWNE ST
Mailing Address - Street 2:APT 1E
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-4514
Mailing Address - Country:US
Mailing Address - Phone:718-640-4976
Mailing Address - Fax:
Practice Address - Street 1:3619 BOWNE ST
Practice Address - Street 2:APT 1E
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-4514
Practice Address - Country:US
Practice Address - Phone:718-640-4976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007225-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant