MEDICARE: DR. LAURA M. GAUGH (PSYD)

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	103TC2200X	Clinical Child & Adolescent Psychologist	8904	MA
2	103TM1800X	Intellectual & Developmental Disabilities Psychologist	8904	MA

General Provider Information

NPI Number	:	1780759613
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURA M. GAUGH (PSYD)

Provider Business Mailing Address
First Line	:	CAMBRIDGE HEALTH ALLIANCE
Second Line	:	STATION LANDING/CCAD 1493 CAMBRIDGE STREET
City	:	CAMBRIDGE
State	:	MA
Zip	:	02139
Country	:	US
Telephone Number	:	781-306-8656
Fax Number	:

Provider Business Practice Location Address
First Line	:	1493 CAMBRIDGE ST
Second Line	:	CAMBRIDGE HEALTH ALLIANCE, STATION LANDING/CCAD
City	:	CAMBRIDGE
State	:	MA
Zip	:	02139-1047
Country	:	US
Telephone Number	:	781-306-8656
Fax Number	:

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

Provider Enumeration Date	:	11/24/2006
Last Update Date	:	09/02/2008

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