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General NPI Number Information
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NPI Number | 1831969161
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Entity Type | Organization
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Legal Business Name | IASO INNOVATIVE RECOVERY CORPORATION
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Dates
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Enumeration Date | 01/08/2024
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Last Update Date | 01/08/2024
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Provider Practice Location Address
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Address Line | 14 SENECA ST
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City | EAST NORTHPORT
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State | NY
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Zip | 11731-1039
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Country | US
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Telephone | 631-897-6493
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Fax |
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Provider Business Mailing Address
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Address Line | 14 SENECA ST
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City | EAST NORTHPORT
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State | NY
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Zip | 11731-1039
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Country | US
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Telephone | 631-897-6493
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | LAURA COLANTUONO
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Credential | PSY.D.
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Telephone | 631-897-6493
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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