Provider Demographics
NPI:1982967881
Name:KIRSHAK, REBECCA LYNN
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:KIRSHAK
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 1:11 ASTOR AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11719-9760
Mailing Address - Country:US
Mailing Address - Phone:631-905-9086
Mailing Address - Fax:
Practice Address - Street 1:11 ASTOR AVE
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11719-9760
Practice Address - Country:US
Practice Address - Phone:631-905-9086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-17
Last Update Date:2012-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY554803174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist