1265998827 NPI number — LAURETTA ELAINE MURDOCK BCBA, LBA

Table of content: LAURETTA ELAINE MURDOCK BCBA, LBA (NPI 1265998827)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265998827 NPI number — LAURETTA ELAINE MURDOCK BCBA, LBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MURDOCK
Provider First Name:
LAURETTA
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BCBA, LBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MURDOCK
Provider Other First Name:
LORETTA
Provider Other Middle Name:
ELAINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
BCBA, LBA
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1265998827
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
C/O THE MOSAIC FOUNDATION FOR AUTISM, INC.
Provider Second Line Business Mailing Address:
1725 BRENTWOOD RD.
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-617-6333
Provider Business Mailing Address Fax Number:
631-617-6334

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
C/O THE MOSAIC FOUNDATION FOR AUTISM, INC.
Provider Second Line Business Practice Location Address:
1725 BRENTWOOD RD.
Provider Business Practice Location Address City Name:
BRENTWOOD
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-617-6333
Provider Business Practice Location Address Fax Number:
631-617-6334
Provider Enumeration Date:
02/19/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103K00000X , with the licence number:  LBA0600 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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