Provider Demographics
NPI:1790134229
Name:BLACK, LAURA (MA, LPC CANDIDATE)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MA, LPC CANDIDATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 S DUNCAN ST
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-3281
Mailing Address - Country:US
Mailing Address - Phone:405-372-9000
Mailing Address - Fax:
Practice Address - Street 1:2224 W 12TH AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-5154
Practice Address - Country:US
Practice Address - Phone:405-377-3380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health