Basic Information
| Provider Information | |||||||||
| NPI: | 1043225618 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITMIRE | ||||||||
| FirstName: | LAURA | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 70 MIDLAND BLVD | ||||||||
| Address2: | |||||||||
| City: | MAPLEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070401808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9734773794 | ||||||||
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| Practice Location | |||||||||
| Address1: | 156 W 56TH ST STE 1804 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128518100 | ||||||||
| FaxNumber: | 2125370102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 06/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 14198 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 02077576 | 05 | NY | MEDICAID |