MEDICARE: LAURA CHEATHAM MA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1427713304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA CHEATHAM MA

Provider Business Mailing Address
First Line	:	268 DEAN ST # 1B
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11217-1806
Country	:	US
Telephone Number	:	757-345-1628
Fax Number	:

Provider Business Practice Location Address
First Line	:	34 PLAZA ST E STE P108
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11238-5047
Country	:	US
Telephone Number	:	908-242-6157
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2021
Last Update Date	:	11/04/2021

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