Provider Demographics
NPI:1932976644
Name:AMEZCUA, LAURA E
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:E
Last Name:AMEZCUA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 GRANDSTAND PL
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-6603
Mailing Address - Country:US
Mailing Address - Phone:847-363-9548
Mailing Address - Fax:
Practice Address - Street 1:39W139 ADOBE RDG
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60124-8478
Practice Address - Country:US
Practice Address - Phone:847-363-9548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician