Provider Demographics
NPI:1982910691
Name:LILAC, LAURA C (PT)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:C
Last Name:LILAC
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 1:8 SAGE LN
Mailing Address - Street 2:
Mailing Address - City:FORT EDWARD
Mailing Address - State:NY
Mailing Address - Zip Code:12828-2486
Mailing Address - Country:US
Mailing Address - Phone:518-366-7438
Mailing Address - Fax:
Practice Address - Street 1:1700 TIBBITS AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-3726
Practice Address - Country:US
Practice Address - Phone:518-328-5801
Practice Address - Fax:518-274-0371
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015497225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist