Provider Demographics
NPI:1881732790
Name:LILLIEBJERG, LAURA (MS)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:LILLIEBJERG
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4441 E STANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:HIGLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85236-3467
Mailing Address - Country:US
Mailing Address - Phone:480-540-4990
Mailing Address - Fax:
Practice Address - Street 1:4601 N 34TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-3320
Practice Address - Country:US
Practice Address - Phone:602-381-6160
Practice Address - Fax:602-381-6170
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ705121Medicaid