Provider Demographics
NPI:1699315317
Name:IMBRIALE, LAURA MARIE
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:MARIE
Last Name:IMBRIALE
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 1:345 N FT LAUDERDALE BCH BLVD APT 703
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-4230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:345 N FT LAUDERDALE BCH BLVD APT 703
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-4230
Practice Address - Country:US
Practice Address - Phone:954-610-1041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW98931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty