Provider Demographics
NPI:1043338973
Name:LARSON, LAURA ANN (MS CCCSLP)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:ANN
Last Name:LARSON
Suffix:
Gender:F
Credentials:MS CCCSLP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ANN
Other - Last Name:HALBERSTADT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1429 N PARSELL CIR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203
Mailing Address - Country:US
Mailing Address - Phone:480-655-1878
Mailing Address - Fax:
Practice Address - Street 1:3839 W CAMELBACK RD
Practice Address - Street 2:ALHAMBRA HIGH SCHOOL
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85019
Practice Address - Country:US
Practice Address - Phone:602-764-6298
Practice Address - Fax:602-271-3497
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0256235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ588684Medicaid