Provider Demographics
NPI:1962730630
Name:HIGGINBOTHAM, LAURA LYNNE (BA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LYNNE
Last Name:HIGGINBOTHAM
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 SARNO RD
Mailing Address - Street 2:SUITE 214
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-4938
Mailing Address - Country:US
Mailing Address - Phone:321-752-3111
Mailing Address - Fax:
Practice Address - Street 1:1600 SARNO RD
Practice Address - Street 2:SUITE 214
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-4938
Practice Address - Country:US
Practice Address - Phone:321-752-3111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health