Provider Demographics
NPI:1710903398
Name:LAUDER, LORETTA L (AUD)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:L
Last Name:LAUDER
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5401
Mailing Address - Fax:740-446-5408
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5401
Practice Address - Fax:740-446-5408
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHA.01057231H00000X
WVA-0129231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000204545OtherOH MEDICAID UNISON
WV9460011000Medicaid
OH0098575Medicaid
OHP00640947OtherRAILROAD MEDICARE
OHLA0797192Medicare PIN