Provider Demographics
NPI:1114404506
Name:ANTHONY, LAURA IDA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:IDA
Last Name:ANTHONY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10130 MALLARD CREEK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-6001
Mailing Address - Country:US
Mailing Address - Phone:704-944-3511
Mailing Address - Fax:
Practice Address - Street 1:10130 MALLARD CREEK ROAD
Practice Address - Street 2:STE 300 #333
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262
Practice Address - Country:US
Practice Address - Phone:704-994-3511
Practice Address - Fax:704-397-3907
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW22193101YM0800X, 1041C0700X
NCC013404101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health