Provider Demographics
NPI:1881463842
Name:FONKEN, LAURIE ELAINE (PHD)
Entity type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:ELAINE
Last Name:FONKEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1631 DOGWOOD CT
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-2022
Mailing Address - Country:US
Mailing Address - Phone:970-988-3894
Mailing Address - Fax:
Practice Address - Street 1:1631 DOGWOOD CT
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-2022
Practice Address - Country:US
Practice Address - Phone:970-988-3894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-01
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO312101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional