Provider Demographics
NPI:1417315631
Name:LAWRENCE, PATRICIA V (MS ED)
Entity type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:V
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:MS ED
Other - Prefix:MS
Other - First Name:PATRICIA
Other - Middle Name:V
Other - Last Name:LAWRENCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSED
Mailing Address - Street 1:140 MIRIN AVE
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:NY
Mailing Address - Zip Code:11575-1624
Mailing Address - Country:US
Mailing Address - Phone:929-434-7076
Mailing Address - Fax:516-442-5105
Practice Address - Street 1:140 MIRIN AVE
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:NY
Practice Address - Zip Code:11575-1624
Practice Address - Country:US
Practice Address - Phone:929-434-7076
Practice Address - Fax:516-442-5105
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-02
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY814020174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1417315631Medicaid