Provider Demographics
NPI:1902442965
Name:SMALL, ATARA (OT)
Entity Type:Individual
Prefix:MRS
First Name:ATARA
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:ATARA
Other - Middle Name:
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2412 OCEANCREST BLVD
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-1929
Mailing Address - Country:US
Mailing Address - Phone:347-608-4488
Mailing Address - Fax:
Practice Address - Street 1:2412 OCEANCREST BLVD
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-1929
Practice Address - Country:US
Practice Address - Phone:347-608-4488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-25
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024187225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist