Basic Information
| Provider Information | |||||||||
| NPI: | 1861599334 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STOCKDALE | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | STOCKDALE | ||||||||
| OtherFirstName: | LAURA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6231 HIGHLAND PLACE WAY | ||||||||
| Address2: | STE 101 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379194083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652642400 | ||||||||
| FaxNumber: | 8655886406 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 WESTFIELD DR | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379194824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8652642400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2006 | ||||||||
| LastUpdateDate: | 09/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | P0000001492 | TN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 4076563 | 01 | TN | BCBS | OTHER | P00106939 | 01 | TN | RAILROAD MEDICARE | OTHER | 3980093 | 05 | TN | MEDICAID |