Provider Demographics
NPI:1205832060
Name:SPAIN, LAURA (ST)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:SPAIN
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8455 S SUNCOAST BLVD
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34446-5066
Mailing Address - Country:US
Mailing Address - Phone:352-860-2220
Mailing Address - Fax:352-860-1181
Practice Address - Street 1:2210 HIGHWAY 44 W
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34453-3860
Practice Address - Country:US
Practice Address - Phone:352-860-2220
Practice Address - Fax:352-860-1181
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA3967235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist