Provider Demographics
NPI:1356664759
Name:INGALLS, LAURA LEE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:LEE
Last Name:INGALLS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:899 RIVERSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1070
Mailing Address - Country:US
Mailing Address - Phone:207-956-3347
Mailing Address - Fax:
Practice Address - Street 1:899 RIVERSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-1070
Practice Address - Country:US
Practice Address - Phone:207-956-3347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-12
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
MELC143811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker