Provider Demographics
NPI:1740517218
Name:DIAZ-FORNO, LAURA E (MA, LPC)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:E
Last Name:DIAZ-FORNO
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1837 DENMARK LN
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045-8385
Mailing Address - Country:US
Mailing Address - Phone:956-251-4204
Mailing Address - Fax:
Practice Address - Street 1:7220 BOB BULLOCK LOOP STE 304
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041
Practice Address - Country:US
Practice Address - Phone:956-251-4204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-04
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX60304101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2070781Medicaid