Healthcare Provider Details

I. General information

NPI: 1114404506
Provider Name (Legal Business Name): LAURA IDA ANTHONY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2018
Last Update Date: 01/31/2026
Certification Date: 01/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12773 MANGROVE FOREST DR
RIVERVIEW FL
33579-2455
US

IV. Provider business mailing address

7901 4TH ST N # 29161
ST PETERSBURG FL
33702-4305
US

V. Phone/Fax

Practice location:
  • Phone: 727-428-8288
  • Fax: 727-295-1938
Mailing address:
  • Phone: 727-428-8288
  • Fax: 727-295-1938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW22193
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904017875
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC013404
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: