Provider Demographics
NPI:1245678432
Name:BARES, LAURA ELISE (MPT, CLT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ELISE
Last Name:BARES
Suffix:
Gender:F
Credentials:MPT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 CHENNAULT AVE
Mailing Address - Street 2:
Mailing Address - City:BARKSDALE AFB
Mailing Address - State:LA
Mailing Address - Zip Code:71110-2038
Mailing Address - Country:US
Mailing Address - Phone:703-973-7725
Mailing Address - Fax:
Practice Address - Street 1:1500 LINE AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4639
Practice Address - Country:US
Practice Address - Phone:318-213-3810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPT04527R225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist