Provider Demographics
NPI:1457468274
Name:MCKIBBIN, LAURA ELIZABETH (LICSW)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:ELIZABETH
Last Name:MCKIBBIN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 AUSTIN RD
Mailing Address - Street 2:SUITE 2 MENTAL HEALTH PROFESSIONALS
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-4402
Mailing Address - Country:US
Mailing Address - Phone:507-446-8123
Mailing Address - Fax:507-446-0600
Practice Address - Street 1:1880 AUSTIN RD
Practice Address - Street 2:SUITE 2 MENTAL HEALTH PROFESSIONALS
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-4402
Practice Address - Country:US
Practice Address - Phone:507-446-8123
Practice Address - Fax:507-446-0600
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA008091041C0700X
MN13543104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA51940OtherWELLMARK
I1488OtherMEDICARE INDIVIDUAL PROVI
I1488OtherMEDICARE INDIVIDUAL PROVI