Provider Demographics
NPI:1366517443
Name:NIEWALD, LAURA JEANNE (MA, LMFT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:JEANNE
Last Name:NIEWALD
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4317 UPTON AVE S
Mailing Address - Street 2:SUITE C
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-1539
Mailing Address - Country:US
Mailing Address - Phone:612-929-1500
Mailing Address - Fax:612-929-1500
Practice Address - Street 1:4317 UPTON AVE S
Practice Address - Street 2:SUITE C
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55410-1539
Practice Address - Country:US
Practice Address - Phone:612-929-1500
Practice Address - Fax:612-929-1500
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1216106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist