Provider Demographics
NPI:1700275369
Name:US, KATHRYN LEE TINC (LAC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:LEE TINC
Last Name:US
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 BERGEN AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:KEARNY
Mailing Address - State:NJ
Mailing Address - Zip Code:07032-2412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:166 BERGEN AVE
Practice Address - Street 2:FL 2
Practice Address - City:KEARNY
Practice Address - State:NJ
Practice Address - Zip Code:07032-2412
Practice Address - Country:US
Practice Address - Phone:973-874-9445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MZ00108900171100000X
NY005323171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist