Provider Demographics
NPI:1700984804
Name:SMITH, LAURA LOUISE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:LOUISE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LAURA
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1 SAN RAFAEL AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-1116
Mailing Address - Country:US
Mailing Address - Phone:505-823-1600
Mailing Address - Fax:505-823-1611
Practice Address - Street 1:1 SAN RAFAEL AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-1116
Practice Address - Country:US
Practice Address - Phone:505-823-1600
Practice Address - Fax:505-823-1611
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2013-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM757103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist