Provider Demographics
NPI:1063518777
Name:VAN ESS, LAURA LEIGH (PTA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LEIGH
Last Name:VAN ESS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4208 W 26TH PL
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-7016
Mailing Address - Country:US
Mailing Address - Phone:417-627-9838
Mailing Address - Fax:
Practice Address - Street 1:100 E VINE ST
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130-3734
Practice Address - Country:US
Practice Address - Phone:615-890-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001002342225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant