Provider Demographics
NPI:1750915922
Name:NISIMOV, MAISEY (MASTERS)
Entity type:Individual
Prefix:
First Name:MAISEY
Middle Name:
Last Name:NISIMOV
Suffix:
Gender:M
Credentials:MASTERS
Other - Prefix:
Other - First Name:MOSHE
Other - Middle Name:
Other - Last Name:NISIMOV
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7602 UTOPIA PKWY
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1518
Mailing Address - Country:US
Mailing Address - Phone:347-209-8282
Mailing Address - Fax:
Practice Address - Street 1:10920 UNION HALL ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11433-2902
Practice Address - Country:US
Practice Address - Phone:347-209-8282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024414-01225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist