Provider Demographics
NPI:1033460746
Name:THEOBALD, LAURA MARIE (MS CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:MARIE
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 SAGAMORE RD
Mailing Address - Street 2:
Mailing Address - City:RYE
Mailing Address - State:NH
Mailing Address - Zip Code:03870-2035
Mailing Address - Country:US
Mailing Address - Phone:207-590-9194
Mailing Address - Fax:
Practice Address - Street 1:346 SAGAMORE RD
Practice Address - Street 2:
Practice Address - City:RYE
Practice Address - State:NH
Practice Address - Zip Code:03870-2035
Practice Address - Country:US
Practice Address - Phone:207-590-9194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0649235Z00000X
MA7656235Z00000X
MESP1066235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist