Provider Demographics
NPI:1093095515
Name:LAURENT, MAKEITA CLAUDIA
Entity Type:Individual
Prefix:
First Name:MAKEITA
Middle Name:CLAUDIA
Last Name:LAURENT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 MILTON AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02124-4519
Mailing Address - Country:US
Mailing Address - Phone:518-330-9394
Mailing Address - Fax:508-634-6984
Practice Address - Street 1:179 MILTON AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-4519
Practice Address - Country:US
Practice Address - Phone:617-314-5365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-29
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
MA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist