Provider Demographics
NPI:1083019509
Name:BANNON, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BANNON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209-1988
Mailing Address - Country:US
Mailing Address - Phone:716-335-7360
Mailing Address - Fax:
Practice Address - Street 1:1325 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14209-1988
Practice Address - Country:US
Practice Address - Phone:716-335-7360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical