Provider Demographics
NPI:1154137081
Name:SOUTHGATE, LAURA ELAINE (MCAP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ELAINE
Last Name:SOUTHGATE
Suffix:
Gender:F
Credentials:MCAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 HANOVER RD
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-8313
Mailing Address - Country:US
Mailing Address - Phone:319-329-5336
Mailing Address - Fax:
Practice Address - Street 1:211 ESLINGER WAY
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32773-6188
Practice Address - Country:US
Practice Address - Phone:407-775-6106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)