Provider Demographics
NPI:1104178938
Name:NATHAN, LAURIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:
Last Name:NATHAN
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 1:939 8TH AVE
Mailing Address - Street 2:#508
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-4264
Mailing Address - Country:US
Mailing Address - Phone:212-586-3334
Mailing Address - Fax:
Practice Address - Street 1:939 8TH AVE
Practice Address - Street 2:#508
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-4264
Practice Address - Country:US
Practice Address - Phone:212-586-3334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015236103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent