Provider Demographics
NPI:1699709790
Name:FRIES, PAULA JEAN (LCAT)
Entity type:Individual
Prefix:MS
First Name:PAULA
Middle Name:JEAN
Last Name:FRIES
Suffix:
Gender:F
Credentials:LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 HAMPTON VISTA DR
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-2861
Mailing Address - Country:US
Mailing Address - Phone:631-874-8618
Mailing Address - Fax:
Practice Address - Street 1:939 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-6066
Practice Address - Country:US
Practice Address - Phone:631-471-7242
Practice Address - Fax:631-471-5150
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000694101YP2500X, 221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional