Provider Demographics
NPI:1912134016
Name:GOODMAN, SHANI SUZANNE (OT/L)
Entity Type:Individual
Prefix:
First Name:SHANI
Middle Name:SUZANNE
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:OT/L
Other - Prefix:
Other - First Name:SHANI
Other - Middle Name:SUZANNE
Other - Last Name:LUBET
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OT/L
Mailing Address - Street 1:1210 BAY 25TH ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-1764
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1210 BAY 25TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-1764
Practice Address - Country:US
Practice Address - Phone:718-471-2615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004666-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist