Provider Demographics
NPI:1578540175
Name:MCDANIELS, LAURA (PSYD, LP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MCDANIELS
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8260 ENCLAVE RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-3038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1789 WOODLANE DR
Practice Address - Street 2:SUITE C
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-3910
Practice Address - Country:US
Practice Address - Phone:651-501-4957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3491103G00000X, 103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN277S6MDOtherBLUE CROSS BLUE SHIELD
MN61-78127OtherMEDICA AND UBH
MN103221OtherHEALTHPARTNERS
MNP00092642OtherRAILROAD MEDICARE
MN141783OtherUCARE AND BHP