Provider Demographics
NPI:1528574084
Name:BECKER, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BECKER
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 1:1155 PALM AVE
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-1626
Mailing Address - Country:US
Mailing Address - Phone:619-799-9517
Mailing Address - Fax:
Practice Address - Street 1:1155 PALM AVE
Practice Address - Street 2:IMPERIAL BEACH
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932-9193
Practice Address - Country:US
Practice Address - Phone:619-799-9517
Practice Address - Fax:619-424-8983
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA588FFDDAC1C09246ZA2600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, Medical