Provider Demographics
NPI:1346633864
Name:LAURIE MINTZ, PH.D., LLC
Entity Type:Organization
Organization Name:LAURIE MINTZ, PH.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MINTZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:573-808-3828
Mailing Address - Street 1:6304 SW 95TH ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-5565
Mailing Address - Country:US
Mailing Address - Phone:573-808-3828
Mailing Address - Fax:
Practice Address - Street 1:2830 NW 41ST ST
Practice Address - Street 2:SUITE D
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-6667
Practice Address - Country:US
Practice Address - Phone:573-808-3828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8648103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL599OUOtherFLORIDA BLUE PROVIDER NUMBER