Provider Demographics
NPI:1134460926
Name:ANDERSON, LAURA SPRAGUE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:SPRAGUE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:LAURA
Other - Middle Name:SPRAGUE
Other - Last Name:ANDERSON-KLONTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1237
Mailing Address - Street 2:
Mailing Address - City:KILAUEA
Mailing Address - State:HI
Mailing Address - Zip Code:96754-1237
Mailing Address - Country:US
Mailing Address - Phone:808-639-1404
Mailing Address - Fax:808-822-4412
Practice Address - Street 1:4-1435 KUHIO HWY
Practice Address - Street 2:SUITE 201
Practice Address - City:KAPAA
Practice Address - State:HI
Practice Address - Zip Code:96746-1745
Practice Address - Country:US
Practice Address - Phone:808-639-1404
Practice Address - Fax:808-822-4412
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY 680103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical