Provider Demographics
NPI:1114075470
Name:VALLEZ, LAURA T
Entity Type:Individual
Prefix:MISS
First Name:LAURA
Middle Name:T
Last Name:VALLEZ
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 1:2679 E BARBARA CIR # Y
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38128-6093
Mailing Address - Country:US
Mailing Address - Phone:901-386-4604
Mailing Address - Fax:
Practice Address - Street 1:1087 ALICE AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38106-6543
Practice Address - Country:US
Practice Address - Phone:901-259-1920
Practice Address - Fax:901-259-1922
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health