Provider Demographics
NPI:1104012038
Name:EGBERT, LAURIE (OT)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:EGBERT
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1724 CAMINO DEL VALLE SW
Mailing Address - Street 2:ADOBE ACRES ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-6003
Mailing Address - Country:US
Mailing Address - Phone:505-877-4799
Mailing Address - Fax:
Practice Address - Street 1:1724 CAMINO DEL VALLE SW
Practice Address - Street 2:ADOBE ACRES ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-6003
Practice Address - Country:US
Practice Address - Phone:505-877-4799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1278225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMT7287Medicaid