Provider Demographics
NPI:1790203230
Name:AGERTON, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:AGERTON
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:PO BOX 60323
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89506-0006
Mailing Address - Country:US
Mailing Address - Phone:775-954-8167
Mailing Address - Fax:
Practice Address - Street 1:9455 SKY VISTA PKWY APT 16A
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89506-2042
Practice Address - Country:US
Practice Address - Phone:775-954-8167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty