Provider Demographics
NPI:1972637551
Name:WERT, LAURA EGERTON (PHD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:EGERTON
Last Name:WERT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5821 STAPLES MILL RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23228-5427
Mailing Address - Country:US
Mailing Address - Phone:804-264-0966
Mailing Address - Fax:804-264-1029
Practice Address - Street 1:5821 STAPLES MILL RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-5427
Practice Address - Country:US
Practice Address - Phone:804-264-0966
Practice Address - Fax:804-264-1029
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810001671103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007712332Medicaid
VA453170OtherBLUE CROSS AND BLUE SHIEL
VA002529OtherVALUE OPTIONS
VA081163OtherSOUTHERN HEALTH
VA414195OtherOPTIMUM/MDIPA
VA081163OtherSOUTHERN HEALTH