Provider Demographics
NPI:1952527418
Name:WORTH, LAURA CROSS
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:CROSS
Last Name:WORTH
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 1:3924 BLAINE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2631
Mailing Address - Country:US
Mailing Address - Phone:314-913-4864
Mailing Address - Fax:314-771-1232
Practice Address - Street 1:4507B LACLEDE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2103
Practice Address - Country:US
Practice Address - Phone:314-913-4864
Practice Address - Fax:314-771-1232
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20020181271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498995604Medicaid