Basic Information
| Provider Information | |||||||||
| NPI: | 1013329333 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LICHTENBERGER | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 635 BELLE TERRE RD | ||||||||
| Address2: | STE 204 | ||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117771977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314740008 | ||||||||
| FaxNumber: | 6314740224 | ||||||||
| Practice Location | |||||||||
| Address1: | 635 BELLE TERRE RD | ||||||||
| Address2: | STE 204 | ||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117771977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314740008 | ||||||||
| FaxNumber: | 6314740224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2014 | ||||||||
| LastUpdateDate: | 11/08/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 037194 | NY | Y | Other Service Providers | Specialist |
No ID Information.