Provider Demographics
NPI:1508337205
Name:VAN DE WATER, LAUREN TAYLOR (DC)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:TAYLOR
Last Name:VAN DE WATER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:TAYLOR
Other - Last Name:CARAZZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:4 E MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:12816-1297
Mailing Address - Country:US
Mailing Address - Phone:518-677-7200
Mailing Address - Fax:
Practice Address - Street 1:4 E MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:NY
Practice Address - Zip Code:12816-1297
Practice Address - Country:US
Practice Address - Phone:518-677-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-07
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013204111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY013204OtherNEW YORK STATE LICENSE