Provider Demographics
NPI:1780215921
Name:BORNEKE, LAURA JEAN (CCC,SLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JEAN
Last Name:BORNEKE
Suffix:
Gender:F
Credentials:CCC,SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37770 25TH ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56048-1906
Mailing Address - Country:US
Mailing Address - Phone:507-340-5249
Mailing Address - Fax:
Practice Address - Street 1:37770 25TH ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:MN
Practice Address - Zip Code:56048-1906
Practice Address - Country:US
Practice Address - Phone:507-340-5249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist