Provider Demographics
NPI:1093264004
Name:PIZZA, LAURA
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:
Last Name:PIZZA
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 1:1710 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-1602
Mailing Address - Country:US
Mailing Address - Phone:215-617-8133
Mailing Address - Fax:
Practice Address - Street 1:10501 DRUMMOND RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19154-3807
Practice Address - Country:US
Practice Address - Phone:215-613-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1-16-23822103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst