Provider Demographics
NPI:1891220364
Name:MELLINGER, LAURA BETH
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:BETH
Last Name:MELLINGER
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 1:3223 N OLIVER ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67220-2106
Mailing Address - Country:US
Mailing Address - Phone:316-267-5437
Mailing Address - Fax:316-267-5444
Practice Address - Street 1:3223 N OLIVER ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67220-2106
Practice Address - Country:US
Practice Address - Phone:316-267-5437
Practice Address - Fax:316-267-5444
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS106E00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1942649116Medicaid