Provider Demographics
NPI:1518666288
Name:ODONOGHUE, LAURIE
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:ODONOGHUE
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 1:126 LOOP DR
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-1517
Mailing Address - Country:US
Mailing Address - Phone:631-805-5590
Mailing Address - Fax:
Practice Address - Street 1:126 LOOP DR
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-1517
Practice Address - Country:US
Practice Address - Phone:631-805-5590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003443101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health