Provider Demographics
NPI:1679852560
Name:GERSON, LAURA ITA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ITA
Last Name:GERSON
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 1:47 KILSYTHE RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-5753
Mailing Address - Country:US
Mailing Address - Phone:781-648-8426
Mailing Address - Fax:
Practice Address - Street 1:47 KILSYTHE RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-5753
Practice Address - Country:US
Practice Address - Phone:781-648-8426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1075271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical