Healthcare Provider Details

I. General information

NPI: 1386345981
Provider Name (Legal Business Name): LAURA BRUSTAD-MATUZA CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 03/13/2023
Certification Date: 03/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532A UNION BLVD
WEST ISLIP NY
11795-3105
US

IV. Provider business mailing address

532A UNION BLVD
WEST ISLIP NY
11795-3105
US

V. Phone/Fax

Practice location:
  • Phone: 631-661-6883
  • Fax: 631-661-7782
Mailing address:
  • Phone: 631-661-6883
  • Fax: 631-661-7782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: