Provider Demographics
NPI:1073593067
Name:COLLINS, LAURA BOOTH (MA CCC SLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:BOOTH
Last Name:COLLINS
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:BOOTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA CCC SLP
Mailing Address - Street 1:109 ASHTON LN
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28147
Mailing Address - Country:US
Mailing Address - Phone:704-633-4271
Mailing Address - Fax:704-633-4271
Practice Address - Street 1:109 ASHTON LN
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-7212
Practice Address - Country:US
Practice Address - Phone:704-633-4271
Practice Address - Fax:704-633-4271
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2142235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2142OtherLICENSE
NC7423724Medicaid