Provider Demographics
NPI:1093919334
Name:ROACH, MIRIAM N
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:N
Last Name:ROACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1458 E 88TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-5120
Mailing Address - Country:US
Mailing Address - Phone:718-906-5451
Mailing Address - Fax:718-096-5488
Practice Address - Street 1:376 BAY 44TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-7103
Practice Address - Country:US
Practice Address - Phone:718-096-5451
Practice Address - Fax:718-096-5488
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001888225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant