Provider Demographics
NPI:1336398056
Name:FORKUM, LAURA (PHD, BCBA-D)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:
Last Name:FORKUM
Suffix:
Gender:F
Credentials:PHD, BCBA-D
Other - Prefix:MRS
Other - First Name:LAURA
Other - Middle Name:FORKUM
Other - Last Name:BERRYHILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD, BCBA-D
Mailing Address - Street 1:3131 QUIET CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37406-4009
Mailing Address - Country:US
Mailing Address - Phone:423-664-0901
Mailing Address - Fax:423-602-9710
Practice Address - Street 1:3131 QUIET CREEK TRL
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37406-4009
Practice Address - Country:US
Practice Address - Phone:423-664-0901
Practice Address - Fax:423-602-9710
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1508054Medicaid