Provider Demographics
NPI:1487383493
Name:WALES, LAURA ANNE
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ANNE
Last Name:WALES
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 1:9015 MURRAY AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-3675
Mailing Address - Country:US
Mailing Address - Phone:408-842-7138
Mailing Address - Fax:
Practice Address - Street 1:9015 MURRAY AVE STE 100
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-3675
Practice Address - Country:US
Practice Address - Phone:408-842-7138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 171M00000X
CAAMFT142374106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171M00000XOther Service ProvidersCase Manager/Care Coordinator