Provider Demographics
NPI:1093454159
Name:JENNICA LAINE-FORMISANO PSYD
Entity type:Organization
Organization Name:JENNICA LAINE-FORMISANO PSYD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNICA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAINE-FORMISANO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:845-489-3687
Mailing Address - Street 1:260 KINGS MALL CT # 331
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-1574
Mailing Address - Country:US
Mailing Address - Phone:845-489-3687
Mailing Address - Fax:845-332-6041
Practice Address - Street 1:260 KINGS MALL CT # 331
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-1574
Practice Address - Country:US
Practice Address - Phone:845-489-3687
Practice Address - Fax:845-332-6041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-27
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)