Provider Demographics
NPI:1952846222
Name:RIAD, MIRA
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:RIAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRA
Other - Middle Name:
Other - Last Name:RIAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:171 WESTERVELT PL
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:NJ
Mailing Address - Zip Code:07644-1105
Mailing Address - Country:US
Mailing Address - Phone:201-932-6464
Mailing Address - Fax:
Practice Address - Street 1:171 WESTERVELT PL
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:NJ
Practice Address - Zip Code:07644-1105
Practice Address - Country:US
Practice Address - Phone:201-932-6464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-22
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010317225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant