Provider Demographics
NPI:1093888497
Name:BALTZELL, LAURA (MSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BALTZELL
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 CARMEL HILL RD N
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:CT
Mailing Address - Zip Code:06751-1602
Mailing Address - Country:US
Mailing Address - Phone:781-308-2259
Mailing Address - Fax:
Practice Address - Street 1:1 RESERVOIR OFFICE PARK
Practice Address - Street 2:STE 204
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-3926
Practice Address - Country:US
Practice Address - Phone:781-308-2259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1022672104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP06711Medicare ID - Type Unspecified