Provider Demographics
NPI:1467235945
Name:CHICAIZA, LAURA CATALINA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:CATALINA
Last Name:CHICAIZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 FLAT MOUNTAIN PASS
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76120-1765
Mailing Address - Country:US
Mailing Address - Phone:817-914-8138
Mailing Address - Fax:
Practice Address - Street 1:313 FLAT MOUNTAIN PASS
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76120-1765
Practice Address - Country:US
Practice Address - Phone:817-914-8138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX687391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical