Provider Demographics
NPI:1871642728
Name:PARKS, LAURA (LSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:PARKS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 MOONLITE DR APT 4
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-2343
Mailing Address - Country:US
Mailing Address - Phone:208-403-6456
Mailing Address - Fax:
Practice Address - Street 1:586 1ST ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-3963
Practice Address - Country:US
Practice Address - Phone:208-529-2920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW-27649104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker