Provider Demographics
NPI:1851999841
Name:LAURA GOTTFRIED LCSW INC.
Entity Type:Organization
Organization Name:LAURA GOTTFRIED LCSW INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOTTFRIED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-773-0073
Mailing Address - Street 1:145 NEWBURY ST STE 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4261
Mailing Address - Country:US
Mailing Address - Phone:207-773-0073
Mailing Address - Fax:
Practice Address - Street 1:145 NEWBURY ST STE 2
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4261
Practice Address - Country:US
Practice Address - Phone:207-773-0073
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1669584058Medicaid