Provider Demographics
NPI:1477082873
Name:MENNECKE, LAURA (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:MENNECKE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:479 JUMPERS HOLE RD STE 304B
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-1732
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:479 JUMPERS HOLE ROAD
Practice Address - Street 2:SUITE 304B
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146
Practice Address - Country:US
Practice Address - Phone:410-693-7171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLPC6877101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health