Healthcare Provider Details

I. General information

NPI: 1962371880
Provider Name (Legal Business Name): MARYAM RAHMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2025
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 ROUTE 111
SMITHTOWN NY
11787-3754
US

IV. Provider business mailing address

11 ROUTE 111
SMITHTOWN NY
11787-3754
US

V. Phone/Fax

Practice location:
  • Phone: 631-920-8351
  • Fax: 631-920-8353
Mailing address:
  • Phone: 631-683-4393
  • Fax: 631-683-4395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: