Provider Demographics
NPI:1134723505
Name:BOBERG, LAURA LYNN (SUDC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LYNN
Last Name:BOBERG
Suffix:
Gender:F
Credentials:SUDC
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:LYNN
Other - Last Name:HUCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:222 W 540 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-6631
Mailing Address - Country:US
Mailing Address - Phone:801-661-7007
Mailing Address - Fax:
Practice Address - Street 1:222 W 540 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-6631
Practice Address - Country:US
Practice Address - Phone:801-661-7007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6855070-6006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
14997547OtherCAQH