Provider Demographics
NPI:1639490543
Name:LAURA DEGRANDIS, PSY.D., LLC
Entity Type:Organization
Organization Name:LAURA DEGRANDIS, PSY.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGRANDIS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:480-385-8223
Mailing Address - Street 1:PO BOX 515381
Mailing Address - Street 2:#9308
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-6681
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:727 N WACO AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-3951
Practice Address - Country:US
Practice Address - Phone:316-616-0260
Practice Address - Fax:316-616-0264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-15
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-LP 1878251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health