Provider Demographics
NPI:1275656746
Name:BURNS, LARA (PT)
Entity Type:Individual
Prefix:MS
First Name:LARA
Middle Name:
Last Name:BURNS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 PATCHOGUE YAPHANK RD
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4899
Mailing Address - Country:US
Mailing Address - Phone:631-775-0971
Mailing Address - Fax:631-475-0975
Practice Address - Street 1:191 PATCHOGUE YAPHANK RD
Practice Address - Street 2:
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4899
Practice Address - Country:US
Practice Address - Phone:631-775-0971
Practice Address - Fax:631-475-0975
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026904-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist