Provider Demographics
NPI:1730645391
Name:LAQUE, SARAH JOANNE (LMT)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:JOANNE
Last Name:LAQUE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 E END RD
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7201
Mailing Address - Country:US
Mailing Address - Phone:907-226-2228
Mailing Address - Fax:907-226-2230
Practice Address - Street 1:880 E END RD
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7201
Practice Address - Country:US
Practice Address - Phone:907-226-2228
Practice Address - Fax:907-226-2230
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK108930225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK600266601Medicaid