Provider Demographics
NPI:1093840985
Name:GREEN, LAURA M (MED CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:GREEN
Suffix:
Gender:F
Credentials:MED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1829 PHILADELPHIA
Mailing Address - Street 2:
Mailing Address - City:WEBB CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64870-1093
Mailing Address - Country:US
Mailing Address - Phone:417-850-4316
Mailing Address - Fax:
Practice Address - Street 1:1401 W AUSTIN ST
Practice Address - Street 2:
Practice Address - City:WEBB CITY
Practice Address - State:MO
Practice Address - Zip Code:64870-1617
Practice Address - Country:US
Practice Address - Phone:417-850-4316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106954235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist