Provider Demographics
NPI:1881460459
Name:PANKUCH, LAUREN (LMHC)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:PANKUCH
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 WILD FLOWER ST
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-8059
Mailing Address - Country:US
Mailing Address - Phone:321-749-7753
Mailing Address - Fax:
Practice Address - Street 1:550 N REO ST STE 215
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-1027
Practice Address - Country:US
Practice Address - Phone:813-538-0385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH22958101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health