=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174410013
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLYDE LACE DE GUZMAN GOROBAT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2025
-----------------------------------------------------
Last Update Date | 12/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4312 56TH STREET, APT F1
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-829-3890
-----------------------------------------------------
Fax | 347-829-3888
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4312 56TH STREET, APT 1F
-----------------------------------------------------
City | WOODSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-829-3890
-----------------------------------------------------
Fax | 347-829-3888
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 054317
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------