Healthcare Provider Details

I. General information

NPI: 1588332878
Provider Name (Legal Business Name): DAWN J LAX MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2021
Last Update Date: 09/01/2021
Certification Date: 09/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 N MAIN ST
NEW SQUARE NY
10977-8916
US

IV. Provider business mailing address

728 N MAIN ST
NEW SQUARE NY
10977-8916
US

V. Phone/Fax

Practice location:
  • Phone: 458-354-9300
  • Fax:
Mailing address:
  • Phone: 458-354-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number113853
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: