Basic Information
| Provider Information | |||||||||
| NPI: | 1871768838 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAURIE SHEA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4127 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240150127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409819394 | ||||||||
| FaxNumber: | 5403117154 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 PONDEROSA DR | ||||||||
| Address2: | SUITE D | ||||||||
| City: | CHRISTIANSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240736598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403821494 | ||||||||
| FaxNumber: | 5403447154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 06/21/2010 | ||||||||
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| AuthorizedOfficialLastName: | SHEA | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5403821494 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 07010013044 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 1821036153 | 05 | VA | MEDICAID |