Basic Information
| Provider Information | |||||||||
| NPI: | 1730576281 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FANWICK | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMHC, NCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 SUNRISE HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | AMITYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316085900 | ||||||||
| FaxNumber: | 6313960382 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 SUNRISE HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | AMITYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316085900 | ||||||||
| FaxNumber: | 6313960382 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2015 | ||||||||
| LastUpdateDate: | 04/22/2015 | ||||||||
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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 | 101YM0800X | 006296 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 00274391 | 05 | NY | MEDICAID |