Provider Demographics
NPI:1477920619
Name:RATHKE, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:RATHKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 N LAKE AVE
Mailing Address - Street 2:7TH FLOOR, AMBULATORY CARE BUILDING, UMASS
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610
Mailing Address - Country:US
Mailing Address - Phone:413-584-4040
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:413-584-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10896103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program