Provider Demographics
NPI:1265547699
Name:CARTER, LAUREL (MS)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:
Last Name:CARTER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:LAUREL
Other - Middle Name:CARTER
Other - Last Name:WILDE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:965 S 100 W
Mailing Address - Street 2:#203
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-6062
Mailing Address - Country:US
Mailing Address - Phone:435-752-1976
Mailing Address - Fax:434-755-6707
Practice Address - Street 1:965 S 100 W
Practice Address - Street 2:#203
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-6062
Practice Address - Country:US
Practice Address - Phone:435-752-1976
Practice Address - Fax:434-755-6707
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2929243902101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health