Healthcare Provider Details

I. General information

NPI: 1114882578
Provider Name (Legal Business Name): PEGAH ANSARI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 FIRST AVENUE
NEWARK NJ
07107
US

IV. Provider business mailing address

66 CHERRY ST
CLIFTON NJ
07014-1316
US

V. Phone/Fax

Practice location:
  • Phone: 973-268-5240
  • Fax:
Mailing address:
  • Phone: 551-358-5173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number41VS01343800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: