Provider Demographics
NPI:1508987132
Name:WHITE, LAURA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:LAURA
Other - Middle Name:E
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:101 PONQUOGUE AVE
Mailing Address - Street 2:
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946-2503
Mailing Address - Country:US
Mailing Address - Phone:631-645-1258
Mailing Address - Fax:631-728-2214
Practice Address - Street 1:101 PONQUOGUE AVE
Practice Address - Street 2:
Practice Address - City:HAMPTON BAYS
Practice Address - State:NY
Practice Address - Zip Code:11946-2503
Practice Address - Country:US
Practice Address - Phone:631-645-1258
Practice Address - Fax:631-728-2214
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR045844-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNH5431Medicare ID - Type Unspecified