Provider Demographics
NPI:1750748521
Name:MASSANET, MIRIAM JANET
Entity type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:JANET
Last Name:MASSANET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 OLINVILLE AVE APT 3G
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-7427
Mailing Address - Country:US
Mailing Address - Phone:646-281-0475
Mailing Address - Fax:
Practice Address - Street 1:275 NORTH ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:NY
Practice Address - Zip Code:10528-1140
Practice Address - Country:US
Practice Address - Phone:914-967-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY384511637171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator