Provider Demographics
NPI:1871768838
Name:LAURIE SHEA
Entity type:Organization
Organization Name:LAURIE SHEA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:540-382-1494
Mailing Address - Street 1:PO BOX 4127
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-0127
Mailing Address - Country:US
Mailing Address - Phone:540-981-9394
Mailing Address - Fax:540-311-7154
Practice Address - Street 1:120 PONDEROSA DR
Practice Address - Street 2:SUITE D
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-6598
Practice Address - Country:US
Practice Address - Phone:540-382-1494
Practice Address - Fax:540-344-7154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA07010013044101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1821036153Medicaid