Provider Demographics
NPI:1134521131
Name:BAILEY, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BAILEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:ROESCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCABA
Mailing Address - Street 1:1501 E PYTHIAN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-2139
Mailing Address - Country:US
Mailing Address - Phone:417-864-7921
Mailing Address - Fax:
Practice Address - Street 1:1613 W ELFINDALE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-1287
Practice Address - Country:US
Practice Address - Phone:417-864-7921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014033311103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst