Provider Demographics
NPI:1235288614
Name:CHAN, LAURA J (NP, LCSW-R)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:CHAN
Suffix:
Gender:F
Credentials:NP, LCSW-R
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Other - Credentials:
Mailing Address - Street 1:STONY BROOK PSYCHIATRIC ASSOCIATES UFPC
Mailing Address - Street 2:HSC LEVEL 10, ROOM 20
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8101
Mailing Address - Country:US
Mailing Address - Phone:631-444-2990
Mailing Address - Fax:631-444-1560
Practice Address - Street 1:STONY BROOK PSYCHIATRIC ASSOCIATES UFPC
Practice Address - Street 2:HSC LEVEL 10, ROOM 20
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8101
Practice Address - Country:US
Practice Address - Phone:631-444-2990
Practice Address - Fax:631-444-1560
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2014-05-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NYR056252-11041C0700X
NYF401211363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300017098Medicare PIN