Provider Demographics
NPI:1376190934
Name:BEVIS, LAURA MARIE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE
Last Name:BEVIS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 SHADY OAKS CT
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-6753
Mailing Address - Country:US
Mailing Address - Phone:574-440-5420
Mailing Address - Fax:
Practice Address - Street 1:905 SHADY OAKS CT
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-6753
Practice Address - Country:US
Practice Address - Phone:574-440-5420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004508A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist