Healthcare Provider Details

I. General information

NPI: 1922768373
Provider Name (Legal Business Name): LAURA ANN WYSOCKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2021
Last Update Date: 12/27/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 E 83RD ST APT 1A
NEW YORK NY
10028-5505
US

IV. Provider business mailing address

408 E 83RD ST APT 1A
NEW YORK NY
10028-5505
US

V. Phone/Fax

Practice location:
  • Phone: 646-420-8600
  • Fax:
Mailing address:
  • Phone: 646-420-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number091594
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: