Provider Demographics
NPI:1952071425
Name:MATTHIESEN, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MATTHIESEN
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 1:145 E DEER FLAT RD
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-1323
Mailing Address - Country:US
Mailing Address - Phone:208-922-9001
Mailing Address - Fax:
Practice Address - Street 1:145 E DEER FLAT RD
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-1323
Practice Address - Country:US
Practice Address - Phone:208-922-9001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-40827104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker