Provider Demographics
NPI:1700420064
Name:DERUBEIS-BYRNE, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:DERUBEIS-BYRNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3123 47TH ST APT 2E
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-1614
Mailing Address - Country:US
Mailing Address - Phone:610-308-2908
Mailing Address - Fax:
Practice Address - Street 1:3123 47TH ST APT 2E
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-1614
Practice Address - Country:US
Practice Address - Phone:610-308-2908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP103209103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical