Provider Demographics
NPI:1215220637
Name:SHUTE, LAURA TERESE
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:TERESE
Last Name:SHUTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:WARE
Mailing Address - State:MA
Mailing Address - Zip Code:01082-1616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:597 OLD MOUNT HOLLY RD STE 300
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-2832
Practice Address - Country:US
Practice Address - Phone:843-501-1099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
SC7058106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1300881Medicaid