Provider Demographics
NPI:1467605022
Name:BACON, LAURA R (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:R
Last Name:BACON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 IRIS CIR
Mailing Address - Street 2:
Mailing Address - City:BEACON
Mailing Address - State:NY
Mailing Address - Zip Code:12508-3931
Mailing Address - Country:US
Mailing Address - Phone:914-391-2094
Mailing Address - Fax:
Practice Address - Street 1:1 IRIS CIR
Practice Address - Street 2:
Practice Address - City:BEACON
Practice Address - State:NY
Practice Address - Zip Code:12508-3931
Practice Address - Country:US
Practice Address - Phone:914-391-2094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2015-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0164661235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist