=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154683555
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. LORIE KATZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2012
-----------------------------------------------------
Last Update Date | 06/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 RANDOPLH DRIVE
-----------------------------------------------------
City | HUNTINGTON STATION
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11746-8308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-793-8809
-----------------------------------------------------
Fax | 631-462-8212
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 RANDOPLH DRIVE
-----------------------------------------------------
City | HUNTINGTON STATION
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11746-8308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-793-8809
-----------------------------------------------------
Fax | 631-462-8212
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------