Provider Demographics
NPI:1669613675
Name:OWEN, LAURA L (LPC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:OWEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 CAMELOT DR APT B
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4746
Mailing Address - Country:US
Mailing Address - Phone:918-316-1381
Mailing Address - Fax:
Practice Address - Street 1:1140 MULBERRY DR
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464
Practice Address - Country:US
Practice Address - Phone:918-453-1108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-20
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1869101YP2500X
OK4116101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional