Provider Demographics
NPI:1144610304
Name:VACHERESSE, LAURA JO (LCSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JO
Last Name:VACHERESSE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:JO
Other - Last Name:ALDRIDGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37354-0278
Mailing Address - Country:US
Mailing Address - Phone:423-442-2622
Mailing Address - Fax:
Practice Address - Street 1:4798 NEW HIGHWAY 68
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37354
Practice Address - Country:US
Practice Address - Phone:423-442-2622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-27
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0006239141041S0200X
TN00000065841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool