Provider Demographics
NPI:1013217462
Name:PEITZ, LAURA ANNE (MS, LPC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ANNE
Last Name:PEITZ
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3415 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74604-1318
Mailing Address - Country:US
Mailing Address - Phone:580-762-5948
Mailing Address - Fax:
Practice Address - Street 1:3415 MEADOW LN
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74604-1318
Practice Address - Country:US
Practice Address - Phone:580-762-5948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3813101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional