Provider Demographics
NPI:1891829354
Name:WIARD, LAURIE AUDRA (MFT)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:AUDRA
Last Name:WIARD
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 MONTANA AVE
Mailing Address - Street 2:#14
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-1353
Mailing Address - Country:US
Mailing Address - Phone:310-266-1929
Mailing Address - Fax:
Practice Address - Street 1:11911 SAN VICENTE BLVD
Practice Address - Street 2:#242
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-5086
Practice Address - Country:US
Practice Address - Phone:310-266-1929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT37032106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist