Healthcare Provider Details

I. General information

NPI: 1134692742
Provider Name (Legal Business Name): HEATHER MISROK OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2019
Last Update Date: 01/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15050 14TH RD
WHITESTONE NY
11357-2609
US

IV. Provider business mailing address

124 2ND AVE APT 4B
NEW YORK NY
10003-8323
US

V. Phone/Fax

Practice location:
  • Phone: 718-767-0071
  • Fax:
Mailing address:
  • Phone: 201-566-4368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number023221
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: