Healthcare Provider Details

I. General information

NPI: 1144754045
Provider Name (Legal Business Name): LAURA VATENOS LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 04/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

791 MARTIN CT W
SEVERN MD
21144-2214
US

IV. Provider business mailing address

791 MARTIN CT W
SEVERN MD
21144-2214
US

V. Phone/Fax

Practice location:
  • Phone: 410-991-0468
  • Fax:
Mailing address:
  • Phone: 410-991-0468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16269
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: