Provider Demographics
NPI:1326889775
Name:GONG, MIAOMIAO
Entity type:Individual
Prefix:
First Name:MIAOMIAO
Middle Name:
Last Name:GONG
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 1:22511 59TH AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:OAKLAND GDNS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-2312
Mailing Address - Country:US
Mailing Address - Phone:646-215-0910
Mailing Address - Fax:
Practice Address - Street 1:248 LARKFIELD RD STE C
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-2443
Practice Address - Country:US
Practice Address - Phone:631-985-7770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-31
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225700000X
NY032286225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist