Healthcare Provider Details

I. General information

NPI: 1508295932
Provider Name (Legal Business Name): LAUREN WITMER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2013
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 MEDFORD AVE SUITE A
PATCHOGUE NY
11772-1233
US

IV. Provider business mailing address

56 MARILYNN ST
EAST ISLIP NY
11730-2703
US

V. Phone/Fax

Practice location:
  • Phone: 631-877-0881
  • Fax:
Mailing address:
  • Phone: 631-877-0881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number386376043
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: