Provider Demographics
NPI:1053439414
Name:ENTWISLE, LAURA M
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:ENTWISLE
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 1:203 N BURTON AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-2310
Mailing Address - Country:US
Mailing Address - Phone:417-866-7818
Mailing Address - Fax:
Practice Address - Street 1:524 W MADISON ST
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-1945
Practice Address - Country:US
Practice Address - Phone:417-326-6284
Practice Address - Fax:417-326-6283
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist