=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154101905
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHRYN LOUISE WRUBLEVSKI LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2023
-----------------------------------------------------
Last Update Date | 09/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2733 MAIN ST
-----------------------------------------------------
City | LAKE PLACID
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12946-3317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-523-3780
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 FAWN RIDGE RD
-----------------------------------------------------
City | LAKE PLACID
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12946-1077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-637-4174
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 024272
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------