Provider Demographics
NPI:1659772564
Name:WHITE, LAURA W
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:W
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:M
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1908 FLINT RD SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-6031
Mailing Address - Country:US
Mailing Address - Phone:256-340-9708
Mailing Address - Fax:256-340-9624
Practice Address - Street 1:3280 DAUPHIN ST
Practice Address - Street 2:SUITE A103
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36606-4060
Practice Address - Country:US
Practice Address - Phone:251-459-8402
Practice Address - Fax:251-459-8403
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH1857225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529917620Medicaid
AL1003819608OtherGROUP NPI
ALK531Medicare UPIN