Provider Demographics
NPI:1124245600
Name:VACLAVIK, LAURA M
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:VACLAVIK
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 1:1 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3415
Mailing Address - Country:US
Mailing Address - Phone:636-327-3800
Mailing Address - Fax:636-327-8611
Practice Address - Street 1:5275 QUAIL RIDGE PKWY
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3553
Practice Address - Country:US
Practice Address - Phone:636-327-3863
Practice Address - Fax:636-327-3956
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002016162225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist