1124187182 NPI number — MS. COLLEEN MARY-GLYNISS LAWRENCE O.T.

Table of content: MS. COLLEEN MARY-GLYNISS LAWRENCE O.T. (NPI 1124187182)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124187182 NPI number — MS. COLLEEN MARY-GLYNISS LAWRENCE O.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAWRENCE
Provider First Name:
COLLEEN
Provider Middle Name:
MARY-GLYNISS
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
O.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124187182
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2001 ROUTE 17M
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GOSHEN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10924-5241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-458-8661
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
462 1ST AVE # A-560
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10016-9196
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-562-2300
Provider Business Practice Location Address Fax Number:
212-562-3486
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  012990 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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