Provider Demographics
NPI:1396342077
Name:HALSTED, LAURA
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:HALSTED
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:HUGHES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3200 E ANEMONE CT
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-6847
Mailing Address - Country:US
Mailing Address - Phone:208-713-2252
Mailing Address - Fax:
Practice Address - Street 1:3200 E ANEMONE CT
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716-6847
Practice Address - Country:US
Practice Address - Phone:208-713-2252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician