Healthcare Provider Details

I. General information

NPI: 1699709790
Provider Name (Legal Business Name): PAULA JEAN FRIES LCAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 JOHNSON AVE
RONKONKOMA NY
11779-6066
US

IV. Provider business mailing address

166 HAMPTON VISTA DR
MANORVILLE NY
11949-2861
US

V. Phone/Fax

Practice location:
  • Phone: 631-471-7242
  • Fax: 631-471-5150
Mailing address:
  • Phone: 631-874-8618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number000694
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number000694
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: