Provider Demographics
NPI:1407878390
Name:BADERTSCHER, LAURA POLIQUIN (CCC/SLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:POLIQUIN
Last Name:BADERTSCHER
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:SMITH
Other - Last Name:POLIQUIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2228 GOLF MANOR BLVD
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-7850
Mailing Address - Country:US
Mailing Address - Phone:813-423-0400
Mailing Address - Fax:
Practice Address - Street 1:10817 BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-3616
Practice Address - Country:US
Practice Address - Phone:813-643-3144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 4559235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8840105Medicaid