Healthcare Provider Details

I. General information

NPI: 1316251911
Provider Name (Legal Business Name): MICHELLE LAVERY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2010
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 STEWART AVE
ROSCOE NY
12776
US

IV. Provider business mailing address

PO BOX 145
ROSCOE NY
12776-0145
US

V. Phone/Fax

Practice location:
  • Phone: 607-498-5653
  • Fax: 607-498-5671
Mailing address:
  • Phone: 607-498-5653
  • Fax: 607-498-5671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0059111
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: