Basic Information
Provider Information | |||||||||
NPI: | 1740644640 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MILLS | ||||||||
FirstName: | LAURIE | ||||||||
MiddleName: | JEAN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT, DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DASHNAU | ||||||||
OtherFirstName: | LAURIE | ||||||||
OtherMiddleName: | JEAN | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 701 LENOX AVE | ||||||||
Address2: |   | ||||||||
City: | ONEIDA | ||||||||
State: | NY | ||||||||
PostalCode: | 134211500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3153639281 | ||||||||
FaxNumber: | 3153639286 | ||||||||
Practice Location | |||||||||
Address1: | 7 MORRILL PL | ||||||||
Address2: |   | ||||||||
City: | FULTON | ||||||||
State: | NY | ||||||||
PostalCode: | 130691530 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3153633389 | ||||||||
FaxNumber: | 3153639286 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/07/2016 | ||||||||
LastUpdateDate: | 04/07/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 0092277-1 | NY | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.