Provider Demographics
NPI:1396217402
Name:TERRAGROSSA, LAURAN M (MSED)
Entity Type:Individual
Prefix:
First Name:LAURAN
Middle Name:M
Last Name:TERRAGROSSA
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:LAURAN
Other - Middle Name:
Other - Last Name:PAVLOV
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSED
Mailing Address - Street 1:538 WILDER ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-5827
Mailing Address - Country:US
Mailing Address - Phone:609-405-1800
Mailing Address - Fax:
Practice Address - Street 1:123 S BROAD ST STE 1948
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19109-1029
Practice Address - Country:US
Practice Address - Phone:609-405-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-31
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health