Provider Demographics
NPI:1568170637
Name:FAU, LIA NICOLE
Entity Type:Individual
Prefix:
First Name:LIA
Middle Name:NICOLE
Last Name:FAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LIA
Other - Middle Name:NICOLE
Other - Last Name:MCLOUGHLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:90 WOODHILLS DR APT 12
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-1493
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:606 OLD ROUTE 17
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-7013
Practice Address - Country:US
Practice Address - Phone:845-794-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027272225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist