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General NPI Number Information
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NPI Number | 1093454159
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Entity Type | Organization
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Legal Business Name | JENNICA LAINE-FORMISANO PSYD
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Dates
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Enumeration Date | 05/27/2022
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Last Update Date | 05/27/2022
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Provider Practice Location Address
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Address Line | 260 KINGS MALL CT # 331
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City | KINGSTON
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State | NY
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Zip | 12401-1574
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Country | US
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Telephone | 845-489-3687
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Fax | 845-332-6041
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Provider Business Mailing Address
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Address Line | 260 KINGS MALL CT # 331
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City | KINGSTON
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State | NY
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Zip | 12401-1574
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Country | US
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Telephone | 845-489-3687
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Fax | 845-332-6041
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Authorized Official
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Title or Position | OWNER
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Name | DR. JENNICA LAINE-FORMISANO
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Credential | PSYD
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Telephone | 845-489-3687
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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