Provider Demographics
NPI:1336480011
Name:BLOMGREN, LAURA ANN (LPC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:BLOMGREN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 MOORE AVE
Mailing Address - Street 2:APT 1105
Mailing Address - City:PORTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78374-3041
Mailing Address - Country:US
Mailing Address - Phone:361-548-6131
Mailing Address - Fax:
Practice Address - Street 1:1404 MOORE AVE
Practice Address - Street 2:APT 1105
Practice Address - City:PORTLAND
Practice Address - State:TX
Practice Address - Zip Code:78374-3041
Practice Address - Country:US
Practice Address - Phone:361-548-6131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67828101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health