Provider Demographics
NPI:1164175923
Name:PANTOURIS, LAURA (CRC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:PANTOURIS
Suffix:
Gender:F
Credentials:CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11419 W PALMETTO PARK RD UNIT 971234
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33497-2560
Mailing Address - Country:US
Mailing Address - Phone:954-546-4358
Mailing Address - Fax:
Practice Address - Street 1:817 N DIXIE HWY
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33060-5621
Practice Address - Country:US
Practice Address - Phone:954-785-8285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225C00000X
95421101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor