Provider Demographics
NPI:1134665110
Name:BALTZ, LAURA (SCHOOL PSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BALTZ
Suffix:
Gender:F
Credentials:SCHOOL PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 WALL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1959
Mailing Address - Country:US
Mailing Address - Phone:618-567-3693
Mailing Address - Fax:
Practice Address - Street 1:785 WALL ST STE 200
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1959
Practice Address - Country:US
Practice Address - Phone:618-567-3693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2137088103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool