Provider Demographics
NPI:1750433561
Name:NACK, LAURA C (LCSW CASAC CEAP)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:C
Last Name:NACK
Suffix:
Gender:F
Credentials:LCSW CASAC CEAP
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:COHEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS ED
Mailing Address - Street 1:1840 211 STREET
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360
Mailing Address - Country:US
Mailing Address - Phone:718-631-2416
Mailing Address - Fax:718-428-1024
Practice Address - Street 1:2350 WATERS EDGE DR
Practice Address - Street 2:S 1E
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360
Practice Address - Country:US
Practice Address - Phone:718-631-2416
Practice Address - Fax:718-631-2416
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR03506911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
N54221Medicare ID - Type Unspecified