Provider Demographics
NPI:1083622468
Name:BAJALIA, LAURIE A (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:A
Last Name:BAJALIA
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:MRS
Other - First Name:LAURIE
Other - Middle Name:BAJALIA
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMFT
Mailing Address - Street 1:1803 CANTERBURY DR STE C
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-0505
Mailing Address - Country:US
Mailing Address - Phone:229-588-4051
Mailing Address - Fax:229-588-4051
Practice Address - Street 1:1803 CANTERBURY DR STE C
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-0505
Practice Address - Country:US
Practice Address - Phone:229-588-4051
Practice Address - Fax:229-588-4051
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT000981106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003227872CMedicaid