Provider Demographics
NPI:1780805143
Name:GOURLAY, LAURA CHRISTINE (MA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:CHRISTINE
Last Name:GOURLAY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 E WISCONSIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2767
Mailing Address - Country:US
Mailing Address - Phone:989-773-9600
Mailing Address - Fax:989-772-3387
Practice Address - Street 1:615 E WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2767
Practice Address - Country:US
Practice Address - Phone:989-773-9600
Practice Address - Fax:989-772-3387
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401000010101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional