Provider Demographics
NPI:1790183697
Name:WILLOUGHBY, LAURA KATHLEEN (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:KATHLEEN
Last Name:WILLOUGHBY
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3882 S CAPULET AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5093
Mailing Address - Country:US
Mailing Address - Phone:208-863-7854
Mailing Address - Fax:
Practice Address - Street 1:3882 S CAPULET AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5093
Practice Address - Country:US
Practice Address - Phone:208-863-7854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1408235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist