Provider Demographics
NPI:1841497864
Name:NIELSEN, LAURA JEAN (PSYD, LP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:JEAN
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:JEAN
Other - Last Name:FARMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2602 13TH AVE E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55109-2440
Mailing Address - Country:US
Mailing Address - Phone:651-769-3360
Mailing Address - Fax:
Practice Address - Street 1:366 SELBY AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1880
Practice Address - Country:US
Practice Address - Phone:651-769-3360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 4759103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent