Provider Demographics
NPI:1043314081
Name:HOLLAND, LAURA WILSON (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:WILSON
Last Name:HOLLAND
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:294 BAYMOUNT DR.
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625
Mailing Address - Country:US
Mailing Address - Phone:704-876-4760
Mailing Address - Fax:704-876-4760
Practice Address - Street 1:510 CARPENTER AVE
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2512
Practice Address - Country:US
Practice Address - Phone:704-663-2115
Practice Address - Fax:704-663-2730
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4117235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412100Medicaid