Provider Demographics
NPI:1427183086
Name:HENCKLER, LAURA JANE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:JANE
Last Name:HENCKLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:LAURA
Other - Middle Name:JANE
Other - Last Name:MIDDLETON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:78 ATLANTIC PLACE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2316
Mailing Address - Country:US
Mailing Address - Phone:207-842-7701
Mailing Address - Fax:207-842-7773
Practice Address - Street 1:453 US ROUTE 1
Practice Address - Street 2:
Practice Address - City:KITTERY
Practice Address - State:ME
Practice Address - Zip Code:03904-5513
Practice Address - Country:US
Practice Address - Phone:207-451-1750
Practice Address - Fax:207-439-4360
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC140401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME003209901Medicare PIN