=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174993182
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA ANN VALLEY MSW, LCSW, CTMH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2015
-----------------------------------------------------
Last Update Date | 10/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 121 E WILLOW BEND DR
-----------------------------------------------------
City | GLEN CARBON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62034-1539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-494-5946
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 121 E WILLOW BEND DR
-----------------------------------------------------
City | GLEN CARBON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62034-1539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-494-5946
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 005386
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------