Provider Demographics
NPI:1871940874
Name:MIZRACHI, MEGHAN (PT)
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:
Last Name:MIZRACHI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 WASHINGTON BLVD
Mailing Address - Street 2:CLUB METRO
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07310-1606
Mailing Address - Country:US
Mailing Address - Phone:201-473-4654
Mailing Address - Fax:
Practice Address - Street 1:1556 3RD AVE
Practice Address - Street 2:STE 211
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-3100
Practice Address - Country:US
Practice Address - Phone:212-353-8693
Practice Address - Fax:347-507-5510
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-19
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01709300225100000X
NY040132225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY040132OtherSTATE LICENSE