Healthcare Provider Details

I. General information

NPI: 1174296685
Provider Name (Legal Business Name): LAUREN PATRUSKY ED.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2021
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10863 BOYETTE RD
RIVERVIEW FL
33569-8012
US

IV. Provider business mailing address

4003 S WEST SHORE BLVD APT 2503
TAMPA FL
33611-1033
US

V. Phone/Fax

Practice location:
  • Phone: 941-993-5639
  • Fax:
Mailing address:
  • Phone: 941-993-5639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSS1513
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: