Provider Demographics
NPI:1851537484
Name:MOOG, LAURA (LMT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MOOG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:EVENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:2005 IRONWOOD PKWY STE 222
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2647
Mailing Address - Country:US
Mailing Address - Phone:208-691-2497
Mailing Address - Fax:208-635-4222
Practice Address - Street 1:2005 IRONWOOD PKWY STE 222
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2647
Practice Address - Country:US
Practice Address - Phone:208-691-2497
Practice Address - Fax:208-635-4222
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-03
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020849225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist