Provider Demographics
NPI:1609981505
Name:KILLOUGH, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:KILLOUGH
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 1:1810 BRIARWOOD ST
Mailing Address - Street 2:
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36066-5587
Mailing Address - Country:US
Mailing Address - Phone:334-365-9634
Mailing Address - Fax:
Practice Address - Street 1:635 MCQUEEN SMITH RD N STE D
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36066-5561
Practice Address - Country:US
Practice Address - Phone:334-365-8063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL2151OtherLICENSE #