Provider Demographics
NPI:1104549609
Name:PHAGOORAM, VENICA (MS OTR/L)
Entity type:Individual
Prefix:MS
First Name:VENICA
Middle Name:
Last Name:PHAGOORAM
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14512 111TH AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435-5616
Mailing Address - Country:US
Mailing Address - Phone:917-379-2868
Mailing Address - Fax:
Practice Address - Street 1:14512 111TH AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435-5616
Practice Address - Country:US
Practice Address - Phone:917-379-2868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018837-01225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist