Healthcare Provider Details

I. General information

NPI: 1689800476
Provider Name (Legal Business Name): MIRIAM FRUCHTER MA, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MIRIAM MOSKOWITZ MA, CCC-SLP

II. Dates (important events)

Enumeration Date: 06/07/2009
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6991 136TH ST
FLUSHING NY
11367-1909
US

IV. Provider business mailing address

6991 136TH ST
FLUSHING NY
11367-1909
US

V. Phone/Fax

Practice location:
  • Phone: 917-376-8479
  • Fax:
Mailing address:
  • Phone: 917-376-8479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number014897
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: