MEDICARE: MISS LAURA MARIE WILBOURN LCAT, ATR-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	221700000X	Art Therapist	002336-01	NY

General Provider Information

NPI Number	:	1295596930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS LAURA MARIE WILBOURN LCAT, ATR-BC

Provider Business Mailing Address
First Line	:	760 E 160TH ST FL 2
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10456-7898
Country	:	US
Telephone Number	:	718-401-5700
Fax Number	:

Provider Business Practice Location Address
First Line	:	402 E 156TH ST
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10455-1232
Country	:	US
Telephone Number	:	646-224-7152
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2024
Last Update Date	:	02/12/2024

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