Healthcare Provider Details

I. General information

NPI: 1982358693
Provider Name (Legal Business Name): KENNETH WOISIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2022
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

261 LAKESHORE BLVD
MASSAPEQUA PARK NY
11762-3026
US

IV. Provider business mailing address

261 LAKESHORE BLVD
MASSAPEQUA PARK NY
11762-3026
US

V. Phone/Fax

Practice location:
  • Phone: 516-220-1941
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number006381
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: