Provider Demographics
NPI:1306615828
Name:CRIAM, MISCILLA
Entity type:Individual
Prefix:
First Name:MISCILLA
Middle Name:
Last Name:CRIAM
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 1:17244 133RD AVE APT 7D
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-3929
Mailing Address - Country:US
Mailing Address - Phone:917-449-3158
Mailing Address - Fax:
Practice Address - Street 1:17244 133RD AVE APT 7D
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-3929
Practice Address - Country:US
Practice Address - Phone:917-449-3158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-26
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004360225100000X
NY004360-01171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist