Provider Demographics
NPI:1306232350
Name:GEBHARDT, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:GEBHARDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 614
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42241-0614
Mailing Address - Country:US
Mailing Address - Phone:270-886-2205
Mailing Address - Fax:270-886-0392
Practice Address - Street 1:3999 FORT CAMPBELL BLVD
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-4929
Practice Address - Country:US
Practice Address - Phone:270-886-2205
Practice Address - Fax:270-886-0392
Is Sole Proprietor?:No
Enumeration Date:2015-04-07
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid