Provider Demographics
NPI:1578863338
Name:GRESHAM, LAURA CRISLER (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:CRISLER
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6063 RIVER CRES
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-4706
Mailing Address - Country:US
Mailing Address - Phone:757-777-2420
Mailing Address - Fax:
Practice Address - Street 1:6063 RIVER CRES
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-4706
Practice Address - Country:US
Practice Address - Phone:757-777-2420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-27
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202006145235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2202006145OtherVA SPEECH LANGUAGE PATHOLOGY LICENSE
12096443OtherAMERICAN SPEECH LANGUAGE AND HEARING ASSOCIATION CERTIFICATION