Provider Demographics
NPI:1164803904
Name:YUSUPOVA, LAURA (LMSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:YUSUPOVA
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 1:11020 71ST RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4914
Mailing Address - Country:US
Mailing Address - Phone:718-263-3355
Mailing Address - Fax:718-263-3373
Practice Address - Street 1:11020 71ST RD
Practice Address - Street 2:SUITE 104
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4914
Practice Address - Country:US
Practice Address - Phone:718-263-3355
Practice Address - Fax:718-263-3373
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY094938-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker