Active NPI
Mira Goldis Wachstock, MA, OTR/L
- Pediatric Occupational Therapist
- Hollis, NY
National Provider Identifier
1881834810
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatric Occupational Therapist
- License
- 010633-1
- Practice address
- 19614 Pompeii Ave
Hollis, NY 11423-1418 - Phone
- (718) 464-0709
- NPI assigned
- Mar 4, 2009
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Occupational Therapist | 225XP0200X | 010633-1 | NY | Primary |
Addresses
Primary practice location
19614 Pompeii Ave
Hollis, NY 11423-1418
Mailing address
19614 Pompeii Ave
Hollis, NY 11423-1418
Phone (718) 464-0709
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Master of Arts
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 010633-1 | NY | MD | Pediatric Occupational Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1236124800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1236124800000",
"number": "1881834810",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "19614 POMPEII AVE",
"city": "HOLLIS",
"state": "NY",
"postal_code": "114231418",
"telephone_number": "718-464-0709"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "19614 POMPEII AVE",
"city": "HOLLIS",
"state": "NY",
"postal_code": "114231418",
"telephone_number": "718-464-0709"
}
],
"practiceLocations": [],
"basic": {
"last_name": "GOLDIS WACHSTOCK",
"first_name": "MIRA",
"credential": "MA, OTR/L",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2009-03-04",
"last_updated": "2009-03-04",
"status": "A"
},
"taxonomies": [
{
"code": "225XP0200X",
"taxonomy_group": "",
"desc": "Occupational Therapist, Pediatrics",
"state": "NY",
"license": "010633-1",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Hollis, NY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 4, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.