Provider Demographics
NPI:1508691551
Name:INNER GLOW EARLY INTERVENTION LLC
Entity type:Organization
Organization Name:INNER GLOW EARLY INTERVENTION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPECIAL INSTRUCTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:V
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:SPECIAL ED TEACHER
Authorized Official - Phone:929-434-7076
Mailing Address - Street 1:140 MIRIN AVE
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:NY
Mailing Address - Zip Code:11575-1624
Mailing Address - Country:US
Mailing Address - Phone:929-434-7076
Mailing Address - Fax:516-442-5105
Practice Address - Street 1:140 MIRIN AVE
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:NY
Practice Address - Zip Code:11575-1624
Practice Address - Country:US
Practice Address - Phone:929-434-7076
Practice Address - Fax:516-442-5105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-07
Last Update Date:2024-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty