Provider Demographics
NPI:1609347673
Name:OMALLY, OSHIN
Entity type:Individual
Prefix:
First Name:OSHIN
Middle Name:
Last Name:OMALLY
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 1:10 WILLIAMS CT
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-5162
Mailing Address - Country:US
Mailing Address - Phone:929-307-7486
Mailing Address - Fax:
Practice Address - Street 1:10 WILLIAMS CT
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-5162
Practice Address - Country:US
Practice Address - Phone:929-307-7486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY126143104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPR12681PMedicaid