Provider Demographics
NPI:1912092396
Name:SOPHOCLEOUS, LAURA MARY (LCSW, LMFT, CASAC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MARY
Last Name:SOPHOCLEOUS
Suffix:
Gender:F
Credentials:LCSW, LMFT, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10-45 NAMEOKE STREET
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691
Mailing Address - Country:US
Mailing Address - Phone:718-327-3723
Mailing Address - Fax:
Practice Address - Street 1:10-45 NAMEOKE STREET
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691
Practice Address - Country:US
Practice Address - Phone:718-327-3723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY084597-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program