Provider Demographics
NPI:1093188138
Name:HORNBACK, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:HORNBACK
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 1:8408 W WILLOW AVENUE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381
Mailing Address - Country:US
Mailing Address - Phone:623-418-6657
Mailing Address - Fax:
Practice Address - Street 1:7402 W SHANGRI LA RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-5812
Practice Address - Country:US
Practice Address - Phone:623-979-8446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-11
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4687101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health