Provider Demographics
NPI:1376662189
Name:WALDVOGEL, LAURA A (MSE, LPC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:WALDVOGEL
Suffix:
Gender:F
Credentials:MSE, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-6214
Mailing Address - Country:US
Mailing Address - Phone:715-845-7175
Mailing Address - Fax:715-845-7142
Practice Address - Street 1:114 GRAND AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-6214
Practice Address - Country:US
Practice Address - Phone:715-845-7175
Practice Address - Fax:715-845-7142
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3231-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40951500Medicaid