Provider Demographics
NPI:1578308649
Name:FUCIK, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:FUCIK
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:PO BOX 29
Mailing Address - Street 2:
Mailing Address - City:BERTRAM
Mailing Address - State:TX
Mailing Address - Zip Code:78605-0029
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:106 ESTRELLA LN
Practice Address - Street 2:
Practice Address - City:BERTRAM
Practice Address - State:TX
Practice Address - Zip Code:78605-4720
Practice Address - Country:US
Practice Address - Phone:512-222-8997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional