=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407138894
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA BETH CONN LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2011
-----------------------------------------------------
Last Update Date | 08/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18 EDINBURGH PL
-----------------------------------------------------
City | CLAYTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-805-0558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18 EDINBURGH PL
-----------------------------------------------------
City | CLAYTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27527-7513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-805-0558
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 1800
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | COO8578
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------