Provider Demographics
NPI:1215976568
Name:TALLEY, LAURA GWEN (PSYD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:GWEN
Last Name:TALLEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 BOB BILLINGS PKWY
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-5810
Mailing Address - Country:US
Mailing Address - Phone:785-842-3681
Mailing Address - Fax:785-856-7595
Practice Address - Street 1:5200 BOB BILLINGS PKWY
Practice Address - Street 2:SUITE 203
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-5810
Practice Address - Country:US
Practice Address - Phone:785-842-3681
Practice Address - Fax:785-856-7595
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLP-0913103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100241830 AMedicaid
KS100241830 AMedicaid