Healthcare Provider Details

I. General information

NPI: 1982967881
Provider Name (Legal Business Name): REBECCA LYNN KIRSHAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2012
Last Update Date: 06/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 ASTOR AVE
BROOKHAVEN NY
11719-9760
US

IV. Provider business mailing address

11 ASTOR AVE
BROOKHAVEN NY
11719-9760
US

V. Phone/Fax

Practice location:
  • Phone: 631-905-9086
  • Fax:
Mailing address:
  • Phone: 631-905-9086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number554803
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: