Provider Demographics
NPI:1710518857
Name:BECKLEY, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BECKLEY
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 1:2423 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-1210
Mailing Address - Country:US
Mailing Address - Phone:260-745-9431
Mailing Address - Fax:
Practice Address - Street 1:5800 FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46807-3400
Practice Address - Country:US
Practice Address - Phone:260-745-9431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator