Provider Demographics
NPI:1154803484
Name:LAURA, CARRIE LYNN (LLMSW, CAADC-DP)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:LYNN
Last Name:LAURA
Suffix:
Gender:F
Credentials:LLMSW, CAADC-DP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14796 SHENANDOAH DR BLDG 24
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48193-7731
Mailing Address - Country:US
Mailing Address - Phone:734-925-2016
Mailing Address - Fax:
Practice Address - Street 1:6309 MACK AVE STE 100
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-2302
Practice Address - Country:US
Practice Address - Phone:313-396-5300
Practice Address - Fax:313-396-5353
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801110369104100000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program