Healthcare Provider Details

I. General information

NPI: 1659647626
Provider Name (Legal Business Name): LAURA L MARR LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2012
Last Update Date: 03/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 FORT SALONGA RD STE 16
FORT SALONGA NY
11768-1454
US

IV. Provider business mailing address

42 SENNE RD
NORTHPORT NY
11768-1417
US

V. Phone/Fax

Practice location:
  • Phone: 631-261-5200
  • Fax:
Mailing address:
  • Phone: 631-261-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number079389-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: