Provider Demographics
NPI:1669003943
Name:PHELPS, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:PHELPS
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 1:438 CONNECTICUT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-2731
Mailing Address - Country:US
Mailing Address - Phone:407-709-0063
Mailing Address - Fax:
Practice Address - Street 1:438 CONNECTICUT AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-2731
Practice Address - Country:US
Practice Address - Phone:407-709-0063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-86507106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician