Provider Demographics
NPI:1376577593
Name:ICKES, LAURA ANN (MS)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:ANN
Last Name:ICKES
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:ANN
Other - Last Name:BASHOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:61055 DAVID RD
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:CO
Mailing Address - Zip Code:81425-9599
Mailing Address - Country:US
Mailing Address - Phone:970-946-4355
Mailing Address - Fax:
Practice Address - Street 1:87 MERCHANT DR
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-3015
Practice Address - Country:US
Practice Address - Phone:970-252-8896
Practice Address - Fax:970-240-3095
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0005232101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional