Provider Demographics
NPI:1154142347
Name:PETTIFOR, LAURA S (EDS)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:S
Last Name:PETTIFOR
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56647 NORTHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:IN
Mailing Address - Zip Code:46540-9119
Mailing Address - Country:US
Mailing Address - Phone:574-533-3151
Mailing Address - Fax:
Practice Address - Street 1:56647 NORTHRIDGE DR
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:IN
Practice Address - Zip Code:46540-9119
Practice Address - Country:US
Practice Address - Phone:574-533-3151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1210541103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool