Provider Demographics
NPI:1376035204
Name:LOUCKS, LAURA (PHD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:LOUCKS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:LOUCKS
Other - Last Name:BRADBURY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2656 PEELER RD
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30360-1904
Mailing Address - Country:US
Mailing Address - Phone:404-712-9788
Mailing Address - Fax:
Practice Address - Street 1:12 EXECUTIVE PARK DR NE STE 300
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2206
Practice Address - Country:US
Practice Address - Phone:404-712-9788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY004189103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist