Provider Demographics
NPI:1053605907
Name:SPRAGUE, LAURA M (DPT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:SPRAGUE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2176 E FRANKLIN RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9024
Mailing Address - Country:US
Mailing Address - Phone:208-288-1155
Mailing Address - Fax:208-288-0424
Practice Address - Street 1:285 VISTA DR
Practice Address - Street 2:SUITE A
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4987
Practice Address - Country:US
Practice Address - Phone:208-478-1488
Practice Address - Fax:208-478-1498
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDPT-2849225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist