Provider Demographics
NPI:1497844013
Name:GOTHAM, LAURA L (ACSW)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:L
Last Name:GOTHAM
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1978 WOODLAND ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR
Mailing Address - State:MI
Mailing Address - Zip Code:48079-5599
Mailing Address - Country:US
Mailing Address - Phone:810-326-4699
Mailing Address - Fax:
Practice Address - Street 1:190 N DELAWARE ST
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:MI
Practice Address - Zip Code:48471-1009
Practice Address - Country:US
Practice Address - Phone:810-583-0313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801088110104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker