Healthcare Provider Details

I. General information

NPI: 1124187182
Provider Name (Legal Business Name): COLLEEN MARY-GLYNISS LAWRENCE O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 02/26/2024
Certification Date: 02/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 1ST AVE # A-560
NEW YORK NY
10016-9196
US

IV. Provider business mailing address

2001 ROUTE 17M
GOSHEN NY
10924-5241
US

V. Phone/Fax

Practice location:
  • Phone: 212-562-2300
  • Fax: 212-562-3486
Mailing address:
  • Phone: 845-458-8661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number012990
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: