=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225669385
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LORI LAGATTUTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2020
-----------------------------------------------------
Last Update Date | 01/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1097 ROUTE 55 STE 6
-----------------------------------------------------
City | LAGRANGEVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12540-5027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-454-4137
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1292 ROUTE 9W
-----------------------------------------------------
City | MARLBORO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12542-5402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-625-4542
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 012409
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------