Healthcare Provider Details

I. General information

NPI: 1174410013
Provider Name (Legal Business Name): CLYDE LACE DE GUZMAN GOROBAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4312 56TH STREET, APT F1
WOODSIDE NY
11377
US

IV. Provider business mailing address

4312 56TH STREET, APT 1F
WOODSIDE NY
11377
US

V. Phone/Fax

Practice location:
  • Phone: 347-829-3890
  • Fax: 347-829-3888
Mailing address:
  • Phone: 347-829-3890
  • Fax: 347-829-3888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number054317
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: