Provider Demographics
NPI:1821374000
Name:VAN ETTEN, LAISLEE SUHEY
Entity Type:Individual
Prefix:
First Name:LAISLEE
Middle Name:SUHEY
Last Name:VAN ETTEN
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 1:8721 SOUTHWICK DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78724-7249
Mailing Address - Country:US
Mailing Address - Phone:512-542-1265
Mailing Address - Fax:
Practice Address - Street 1:8721 SOUTHWICK DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78724-7249
Practice Address - Country:US
Practice Address - Phone:512-542-1265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0003914235Z00000X
TX116605235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX207164901Medicaid
TX456606Medicare PIN
TX207164901Medicaid