Provider Demographics
NPI:1528540234
Name:GANTZ, LAUREN NICOLE (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:NICOLE
Last Name:GANTZ
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:256 WOODCREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14223-1412
Mailing Address - Country:US
Mailing Address - Phone:716-310-7492
Mailing Address - Fax:
Practice Address - Street 1:3767 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1040
Practice Address - Country:US
Practice Address - Phone:716-874-6175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022862225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist