Provider Demographics
NPI:1538390406
Name:WILLARD, LAURA ELISABETH (PSYD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ELISABETH
Last Name:WILLARD
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 CAMINO DEL RIO S
Mailing Address - Street 2:STE 205
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3719
Mailing Address - Country:US
Mailing Address - Phone:619-356-0451
Mailing Address - Fax:619-916-2142
Practice Address - Street 1:2525 CAMINO DEL RIO S
Practice Address - Street 2:STE 205
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3719
Practice Address - Country:US
Practice Address - Phone:619-356-0451
Practice Address - Fax:619-916-2142
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26863103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist