Provider Demographics
NPI:1043886047
Name:UPCHURCH, LAURIE ELIZABETH (MA)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:ELIZABETH
Last Name:UPCHURCH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 678
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39130-0678
Mailing Address - Country:US
Mailing Address - Phone:601-850-9300
Mailing Address - Fax:
Practice Address - Street 1:141 TOWNSHIP AVE STE 303
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-8699
Practice Address - Country:US
Practice Address - Phone:601-921-7522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2022-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2834101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health