Provider Demographics
NPI:1104603588
Name:DEROSIER-MORAN, LAURA MICHELLE (MA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MICHELLE
Last Name:DEROSIER-MORAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 DUPONT AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55412-1330
Mailing Address - Country:US
Mailing Address - Phone:406-366-4201
Mailing Address - Fax:
Practice Address - Street 1:299 COON RAPIDS BLVD NW STE 100
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5869
Practice Address - Country:US
Practice Address - Phone:763-363-6219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist