Provider Demographics
NPI:1164921193
Name:LADUC, MISTY DAWN
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:DAWN
Last Name:LADUC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 506
Mailing Address - Street 2:
Mailing Address - City:SACKETS HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:13685-0506
Mailing Address - Country:US
Mailing Address - Phone:315-836-7401
Mailing Address - Fax:
Practice Address - Street 1:22107 FABCO RD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1737
Practice Address - Country:US
Practice Address - Phone:315-681-6669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician