=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629689005
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALICIA GRUNDER-LAUGHLIN MPS, ATR-BC, LCAT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2020
-----------------------------------------------------
Last Update Date | 08/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4513 OLD VESTAL RD
-----------------------------------------------------
City | VESTAL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13850-3571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-269-7350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 507 OVERLOOK TER
-----------------------------------------------------
City | ENDICOTT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13760-4629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 002239
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------