=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467176602
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MONIQUE JONES LGPAT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2022
-----------------------------------------------------
Last Update Date | 09/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 555 BROADHOLLOW RD STE 101
-----------------------------------------------------
City | MELVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11747-5001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-375-9545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 48 PARKWAY AVE
-----------------------------------------------------
City | AMITYVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11701-1311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-375-9545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 221700000X
-----------------------------------------------------
Taxonomy Name | Art Therapist
-----------------------------------------------------
License Number | P111895
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------