Provider Demographics
NPI:1154929271
Name:SQUIBBS, LAURA MAE
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MAE
Last Name:SQUIBBS
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 1:2174 NILES CORTLAND ROAD NORTH EAST
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-2719
Mailing Address - Country:US
Mailing Address - Phone:330-360-6399
Mailing Address - Fax:
Practice Address - Street 1:1319 FLORENCEDALE AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-2719
Practice Address - Country:US
Practice Address - Phone:330-743-4673
Practice Address - Fax:330-743-1073
Is Sole Proprietor?:No
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH172253101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)