Provider Demographics
NPI:1134217748
Name:SIERCKS, LAURA HOWERY (LICSW)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:HOWERY
Last Name:SIERCKS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MRS
Other - First Name:LAURA
Other - Middle Name:N
Other - Last Name:AFTEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1015 S BROADWAY
Mailing Address - Street 2:SUITE 18
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-4667
Mailing Address - Country:US
Mailing Address - Phone:701-857-8500
Mailing Address - Fax:701-857-8555
Practice Address - Street 1:1015 S BROADWAY
Practice Address - Street 2:SUITE 18
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4667
Practice Address - Country:US
Practice Address - Phone:701-857-8500
Practice Address - Fax:701-857-8555
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND29341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54517Medicaid
ND025967OtherBCBS