Provider Demographics
NPI:1053522581
Name:HALLIBURTON, LAURA J (PT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:HALLIBURTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:J
Other - Last Name:BONHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:3301 BERRYWOOD DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6517
Mailing Address - Country:US
Mailing Address - Phone:573-449-8771
Mailing Address - Fax:573-449-6563
Practice Address - Street 1:3301 BERRYWOOD DR
Practice Address - Street 2:SUITE 204
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6517
Practice Address - Country:US
Practice Address - Phone:573-449-8771
Practice Address - Fax:573-449-6563
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002007670225200000X
MO2007014584225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOL35F386Medicare PIN