Provider Demographics
NPI:1275076432
Name:DECKER, LAURA (LMT)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:
Last Name:DECKER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 MUNDY ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-6830
Mailing Address - Country:US
Mailing Address - Phone:570-344-3788
Mailing Address - Fax:570-614-0212
Practice Address - Street 1:150 MUNDY ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-6830
Practice Address - Country:US
Practice Address - Phone:570-344-3788
Practice Address - Fax:570-614-0212
Is Sole Proprietor?:No
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG011106225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist