Provider Demographics
NPI:1235148958
Name:MACKNER, LAURA M (PHD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:MACKNER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 NORTHRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-3327
Mailing Address - Country:US
Mailing Address - Phone:614-596-8574
Mailing Address - Fax:
Practice Address - Street 1:9734 JUG ST. NW
Practice Address - Street 2:PBJ CONNECTIONS
Practice Address - City:PATASKALA
Practice Address - State:OH
Practice Address - Zip Code:43062
Practice Address - Country:US
Practice Address - Phone:740-924-7543
Practice Address - Fax:740-924-2002
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2025-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5812103T00000X
OHP.5812103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2302056OtherBCMH
OH2302056Medicaid