Provider Demographics
NPI:1629306303
Name:SANTOMAURO, LAURAQ ELISE (MFT)
Entity Type:Individual
Prefix:MRS
First Name:LAURAQ
Middle Name:ELISE
Last Name:SANTOMAURO
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1600
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-1600
Mailing Address - Country:US
Mailing Address - Phone:307-690-2153
Mailing Address - Fax:
Practice Address - Street 1:460 SOUTH JACKSON AVE.
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-690-2153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPMFT 229106H00000X
WY251C00000X106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist