Provider Demographics
NPI:1700766813
Name:KWONG, LAURA MARIE MICHELLE
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE MICHELLE
Last Name:KWONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:MARIE MICHELLE
Other - Last Name:HEEGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1111 VAN NESS AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-2002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29143 AUBERRY RD
Practice Address - Street 2:
Practice Address - City:PRATHER
Practice Address - State:CA
Practice Address - Zip Code:93651-9757
Practice Address - Country:US
Practice Address - Phone:559-855-3662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA210102690103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool