Provider Demographics
NPI:1609053289
Name:FRAZIER, LAURETTE SUSAN (PHARMACIST, DSP)
Entity Type:Individual
Prefix:
First Name:LAURETTE
Middle Name:SUSAN
Last Name:FRAZIER
Suffix:
Gender:F
Credentials:PHARMACIST, DSP
Other - Prefix:
Other - First Name:LAURETTE
Other - Middle Name:SUSAN
Other - Last Name:FRAZIER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PASTORAL COUNSELOR
Mailing Address - Street 1:894 E MILLER DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-6712
Mailing Address - Country:US
Mailing Address - Phone:812-679-2207
Mailing Address - Fax:
Practice Address - Street 1:2815 E 10TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-2601
Practice Address - Country:US
Practice Address - Phone:812-679-2207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-26
Last Update Date:2023-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110997101YP1600X
IN26015089A183500000X
IN197509246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No183500000XPharmacy Service ProvidersPharmacist