Provider Demographics
NPI:1619378825
Name:NISSANIAN, MOSHE (OTR/L)
Entity type:Individual
Prefix:
First Name:MOSHE
Middle Name:
Last Name:NISSANIAN
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 N WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-1925
Mailing Address - Country:US
Mailing Address - Phone:917-751-0010
Mailing Address - Fax:
Practice Address - Street 1:1112 N WILSON AVE
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-1925
Practice Address - Country:US
Practice Address - Phone:917-751-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-07
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00834900225X00000X
NY019077225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist