Provider Demographics
NPI:1558715235
Name:DEFENBACH, LAURA MAE (MS, CGC)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:MAE
Last Name:DEFENBACH
Suffix:
Gender:F
Credentials:MS, CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 N 1ST ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6100
Mailing Address - Country:US
Mailing Address - Phone:208-381-3088
Mailing Address - Fax:208-381-4314
Practice Address - Street 1:333 N 1ST ST
Practice Address - Street 2:SUITE 150
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6100
Practice Address - Country:US
Practice Address - Phone:208-381-3088
Practice Address - Fax:208-381-4314
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS