Provider Demographics
NPI:1407003635
Name:VANDEUSEN, LAURIE VIRGINIA (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:VIRGINIA
Last Name:VANDEUSEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 S WOODHILL AVE
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13904-2726
Mailing Address - Country:US
Mailing Address - Phone:607-775-1451
Mailing Address - Fax:
Practice Address - Street 1:1277 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:OWEGO
Practice Address - State:NY
Practice Address - Zip Code:13827-1200
Practice Address - Country:US
Practice Address - Phone:607-687-8929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY066621-11041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool