Provider Demographics
NPI:1053550251
Name:MOSER, LAURIE A (MA)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
Last Name:MOSER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1533
Mailing Address - Country:US
Mailing Address - Phone:612-596-7071
Mailing Address - Fax:952-348-5447
Practice Address - Street 1:525 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1533
Practice Address - Country:US
Practice Address - Phone:612-596-7071
Practice Address - Fax:952-348-5447
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1820106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist