Provider Demographics
NPI:1942964010
Name:LOUIS, GRACEMARIE FONG (LCAT, ATR-BC)
Entity Type:Individual
Prefix:
First Name:GRACEMARIE
Middle Name:FONG
Last Name:LOUIS
Suffix:
Gender:F
Credentials:LCAT, ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 NEWTOWN RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946-1910
Mailing Address - Country:US
Mailing Address - Phone:516-361-4837
Mailing Address - Fax:
Practice Address - Street 1:1527 5TH ST
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-4541
Practice Address - Country:US
Practice Address - Phone:631-867-2501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt TherapistGroup - Single Specialty