Healthcare Provider Details

I. General information

NPI: 1851892491
Provider Name (Legal Business Name): LAURA KONAXIS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA THIBEAULT

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 LEBANON ST
MELROSE MA
02176-3225
US

IV. Provider business mailing address

18 LONGBOW RD
STONEHAM MA
02180-3468
US

V. Phone/Fax

Practice location:
  • Phone: 781-979-3300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number120789
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: