Provider Demographics
NPI:1629383690
Name:HAARSTAD, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:HAARSTAD
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 1:540 E LA PASADA BLVD
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-1368
Mailing Address - Country:US
Mailing Address - Phone:623-772-4310
Mailing Address - Fax:
Practice Address - Street 1:540 E LA PASADA BLVD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-1368
Practice Address - Country:US
Practice Address - Phone:623-772-4310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ502787535101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool