Provider Demographics
NPI:1457511214
Name:LARUE, LAUWANNA R (LMT)
Entity Type:Individual
Prefix:
First Name:LAUWANNA
Middle Name:R
Last Name:LARUE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:749 MCCUBBINS DR
Mailing Address - Street 2:
Mailing Address - City:LINN CREEK
Mailing Address - State:MO
Mailing Address - Zip Code:65052-1729
Mailing Address - Country:US
Mailing Address - Phone:573-216-5510
Mailing Address - Fax:
Practice Address - Street 1:54 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3050
Practice Address - Country:US
Practice Address - Phone:573-302-2230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-13
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004014743225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist