Basic Information
| Provider Information | |||||||||
| NPI: | 1932763968 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAGADORN | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RYFUN | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 81 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146081410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853686900 | ||||||||
| FaxNumber: | 5855465806 | ||||||||
| Practice Location | |||||||||
| Address1: | 81 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146081410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853686900 | ||||||||
| FaxNumber: | 5855465806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2019 | ||||||||
| LastUpdateDate: | 04/25/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 29425 | NY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.