Provider Demographics
NPI:1598275695
Name:MARSHALL, LAURA ANNE
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ANNE
Last Name:MARSHALL
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 1:7366 ROYAL BIRKDALE DR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34238-2820
Mailing Address - Country:US
Mailing Address - Phone:978-400-8102
Mailing Address - Fax:
Practice Address - Street 1:USF BIRCH DRIVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33620-0001
Practice Address - Country:US
Practice Address - Phone:978-400-8102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106S00000XMedicaid