Provider Demographics
NPI:1134842768
Name:ATEHORTUA, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:ATEHORTUA
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 1:10 HILLSIDE AVE APT 10
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-3076
Mailing Address - Country:US
Mailing Address - Phone:201-606-5756
Mailing Address - Fax:
Practice Address - Street 1:101 CRAWFORDS CORNER RD
Practice Address - Street 2:
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733-1976
Practice Address - Country:US
Practice Address - Phone:732-683-2322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTP223-047103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJTP223-047OtherBCBS, AETNA