Provider Demographics
NPI:1689791352
Name:DRESDALE, LAWRENCE EDWARD (PHD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:EDWARD
Last Name:DRESDALE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 BROADWAY # 201
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-3449
Mailing Address - Country:US
Mailing Address - Phone:845-331-2007
Mailing Address - Fax:845-339-2382
Practice Address - Street 1:159 GREEN ST.
Practice Address - Street 2:SUITE 1
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401
Practice Address - Country:US
Practice Address - Phone:845-339-2352
Practice Address - Fax:845-339-2382
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2018-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007948103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00977344Medicaid
NY986103OtherMVP HEALTHCARE
NY135390OtherVALUEOPTIONS
NY986103OtherMVP HEALTHCARE