Provider Demographics
NPI:1629780929
Name:FOURNILLIER, LAURA HELENE (MA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:HELENE
Last Name:FOURNILLIER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:HELENE
Other - Last Name:VEGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:2139 W STATE ROAD 434 STE 102
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-5019
Mailing Address - Country:US
Mailing Address - Phone:407-789-2673
Mailing Address - Fax:
Practice Address - Street 1:2139 W STATE ROAD 434 STE 102
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-5019
Practice Address - Country:US
Practice Address - Phone:407-789-2673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health