Provider Demographics
NPI:1699255844
Name:SHRUB OAK CLINICAL SERVICES OT, PT, SLP, LMSW, PSYCHOLOGY, PLLC
Entity type:Organization
Organization Name:SHRUB OAK CLINICAL SERVICES OT, PT, SLP, LMSW, PSYCHOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:KOFFLER
Authorized Official - Suffix:
Authorized Official - Credentials:SLP
Authorized Official - Phone:917-696-2171
Mailing Address - Street 1:80 BROAD ST STE 1702
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10004-2248
Mailing Address - Country:US
Mailing Address - Phone:212-867-2922
Mailing Address - Fax:
Practice Address - Street 1:80 BROAD ST STE 1702
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10004-2248
Practice Address - Country:US
Practice Address - Phone:212-867-2922
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014220103T00000X
0973811041C0700X
NY035660225100000X
NY016818225X00000X
NY02141235Z00000X
NY002141235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY016818OtherNEW YORK STATE EDUCATION DEPARTMENT
NY035660OtherNEW YORK STATE EDUCATION DEPARTMENT
NY014220OtherNEW YORK STATE EDUCATION DEPARTMENT
NY002141OtherNEW YORK STATE EDUCATION DEPARTMENT
NY097381OtherNEW YORK STATE EDUCATION DEPARTMENT