Provider Demographics
NPI:1629546114
Name:WEIDNER, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WEIDNER
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 1:159 LAWNSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINGSWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08108-1937
Mailing Address - Country:US
Mailing Address - Phone:609-744-0438
Mailing Address - Fax:
Practice Address - Street 1:159 LAWNSIDE AVE
Practice Address - Street 2:
Practice Address - City:COLLINGSWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08108-1937
Practice Address - Country:US
Practice Address - Phone:609-744-0438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor