Basic Information
| Provider Information | |||||||||
| NPI: | 1568929578 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROGNO | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COSTANTINO | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6501 N CHARLES ST RM D225 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212046819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109383464 | ||||||||
| FaxNumber: | 4109385131 | ||||||||
| Practice Location | |||||||||
| Address1: | 6701 N CHARLES ST STE 5105 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212046808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4438492397 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2019 | ||||||||
| LastUpdateDate: | 02/26/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 12801 | MD | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.