Provider Demographics
NPI:1619545266
Name:ANTHOLZ, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:ANTHOLZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SPENCER
Other - Middle Name:DEREK
Other - Last Name:ANTHOLZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:41 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-1822
Mailing Address - Country:US
Mailing Address - Phone:402-660-6539
Mailing Address - Fax:
Practice Address - Street 1:41 SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-1822
Practice Address - Country:US
Practice Address - Phone:402-660-6539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician