Basic Information
| Provider Information | |||||||||
| NPI: | 1275147779 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHANG | ||||||||
| FirstName: | LAUREN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 576 BROADHOLLOW RD | ||||||||
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| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117475002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313595859 | ||||||||
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| Practice Location | |||||||||
| Address1: | 590 ANDERSON AVE | ||||||||
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| City: | CLIFFSIDE PARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070101721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2019418667 | ||||||||
| FaxNumber: | 2019413353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2020 | ||||||||
| LastUpdateDate: | 09/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01939500 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.