Healthcare Provider Details

I. General information

NPI: 1770147985
Provider Name (Legal Business Name): LAUREN ROTKO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 04/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 STEWART AVE
GARDEN CITY NY
11530-4783
US

IV. Provider business mailing address

11 BEACON HILL RD
PORT WASHINGTON NY
11050-3027
US

V. Phone/Fax

Practice location:
  • Phone: 516-280-7285
  • Fax:
Mailing address:
  • Phone: 516-944-3090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0563218
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: