Provider Demographics
NPI:1285668400
Name:DERR, LAURA SEELY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:SEELY
Last Name:DERR
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 NEPONSET AVE
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-2123
Mailing Address - Country:US
Mailing Address - Phone:781-713-4707
Mailing Address - Fax:
Practice Address - Street 1:1017 TURNPIKE ST.
Practice Address - Street 2:SUITE 12C
Practice Address - City:CANTON
Practice Address - State:MA
Practice Address - Zip Code:02021-2847
Practice Address - Country:US
Practice Address - Phone:781-713-4707
Practice Address - Fax:781-713-4708
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6680103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA798610OtherTUFTS HMO
MAW05804OtherBCBS HMO PPO FEDERAL
MA0524069Medicaid
MA798610OtherTUFTS HMO