Provider Demographics
NPI:1043379209
Name:MCINTYRE, LAURA LEE (PHD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LEE
Last Name:MCINTYRE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 SALINA MEADOWS PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-4584
Mailing Address - Country:US
Mailing Address - Phone:315-464-2096
Mailing Address - Fax:315-464-2010
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2306
Practice Address - Country:US
Practice Address - Phone:315-464-4842
Practice Address - Fax:315-464-7564
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016432103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02832259Medicaid
NYRB2997Medicare PIN