Healthcare Provider Details

I. General information

NPI: 1528541315
Provider Name (Legal Business Name): MISS LAUREN SARA ROY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2018
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

358 SAINT MARKS PL FL 5
STATEN ISLAND NY
10301-2417
US

IV. Provider business mailing address

167 QUEEN ST
STATEN ISLAND NY
10314-5175
US

V. Phone/Fax

Practice location:
  • Phone: 646-942-7897
  • Fax:
Mailing address:
  • Phone: 347-893-3613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number657448956
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number109857
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: