Provider Demographics
NPI:1134567837
Name:BINGHAM, LAURA M (LMSW)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:BINGHAM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2235 E 25TH ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7519
Mailing Address - Country:US
Mailing Address - Phone:208-522-9812
Mailing Address - Fax:208-522-9859
Practice Address - Street 1:2235 E 25TH ST
Practice Address - Street 2:SUITE 220
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7519
Practice Address - Country:US
Practice Address - Phone:208-522-9812
Practice Address - Fax:208-522-9859
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-33021104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1881708832Medicaid