Provider Demographics
NPI:1164643870
Name:GILLINGHAM, LAURIE L (LMSW)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:L
Last Name:GILLINGHAM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 S LAKESHORE RD
Mailing Address - Street 2:
Mailing Address - City:CARSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48419-9494
Mailing Address - Country:US
Mailing Address - Phone:810-689-4846
Mailing Address - Fax:810-958-1430
Practice Address - Street 1:1115 S VAN DYKE RD STE 1
Practice Address - Street 2:
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413-9615
Practice Address - Country:US
Practice Address - Phone:810-689-4846
Practice Address - Fax:810-958-1430
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0070091041C0700X
MI6801087191104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M29340Medicare ID - Type Unspecified
MI0C26043010Medicare PIN