Healthcare Provider Details

I. General information

NPI: 1437624822
Provider Name (Legal Business Name): LAURA GERMAINE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2018
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 E MAIN ST
BABYLON NY
11702-3526
US

IV. Provider business mailing address

7555 MAIN RD
MATTITUCK NY
11952-1516
US

V. Phone/Fax

Practice location:
  • Phone: 631-751-3000
  • Fax: 631-751-0506
Mailing address:
  • Phone: 631-405-3172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number092970
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number102180
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: