Provider Demographics
NPI:1427125293
Name:DERMER, LAURA ELIZABETH (LCSW)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ELIZABETH
Last Name:DERMER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 W END AVE
Mailing Address - Street 2:
Mailing Address - City:OLD GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06870-1640
Mailing Address - Country:US
Mailing Address - Phone:203-536-6555
Mailing Address - Fax:
Practice Address - Street 1:3 W END AVE
Practice Address - Street 2:
Practice Address - City:OLD GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06870-1640
Practice Address - Country:US
Practice Address - Phone:203-536-6555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0052811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004172920Medicaid
CT004172912Medicaid
CT004172920Medicaid