Healthcare Provider Details

I. General information

NPI: 1649678731
Provider Name (Legal Business Name): LAURA MALICK RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2014
Last Update Date: 08/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 BLAKE AVE
BROOKLYN NY
11208-3535
US

IV. Provider business mailing address

60 MADISON AVE 5TH FLOOR
NEW YORK NY
10010-1600
US

V. Phone/Fax

Practice location:
  • Phone: 718-277-8303
  • Fax: 212-277-4795
Mailing address:
  • Phone: 212-545-2439
  • Fax: 646-312-0481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number008187
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: