Provider Demographics
NPI:1952363947
Name:WASTOWICZ, LAURA STEPHANIA (PT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:STEPHANIA
Last Name:WASTOWICZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206-1916
Mailing Address - Country:US
Mailing Address - Phone:518-262-9700
Mailing Address - Fax:518-262-9720
Practice Address - Street 1:618 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-1916
Practice Address - Country:US
Practice Address - Phone:518-262-9700
Practice Address - Fax:518-262-9720
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013673-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist