Provider Demographics
NPI:1851136410
Name:SOUTHWICK, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:SOUTHWICK
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 1:1809 E SPRINGDALE WAY
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8864
Mailing Address - Country:US
Mailing Address - Phone:516-581-4652
Mailing Address - Fax:
Practice Address - Street 1:3002 W 12600 S
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7119
Practice Address - Country:US
Practice Address - Phone:801-930-0411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker