Provider Demographics
NPI:1508088386
Name:LAURENT, JEAN (PTA)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:LAURENT
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 W END AVE
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-5349
Mailing Address - Country:US
Mailing Address - Phone:845-564-9853
Mailing Address - Fax:845-564-6974
Practice Address - Street 1:825 W END AVE
Practice Address - Street 2:SUITE 1A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-5349
Practice Address - Country:US
Practice Address - Phone:845-564-9853
Practice Address - Fax:845-564-6974
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005624-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY005624-1OtherPTA LICENSE