Provider Demographics
NPI:1811555238
Name:HAGGERTY, LAWRENCE (CASAC)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:HAGGERTY
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-2763
Mailing Address - Country:US
Mailing Address - Phone:718-815-3155
Mailing Address - Fax:
Practice Address - Street 1:201 FOREST AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2763
Practice Address - Country:US
Practice Address - Phone:718-815-3155
Practice Address - Fax:718-815-3151
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2-4752101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)