Provider Demographics
NPI:1760774194
Name:NG, LAURA
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:NG
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 1:2222 S 114TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53227-1031
Mailing Address - Country:US
Mailing Address - Phone:414-449-4444
Mailing Address - Fax:
Practice Address - Street 1:2222 S 114TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-1031
Practice Address - Country:US
Practice Address - Phone:414-449-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-03
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69-140103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41209100Medicaid