Provider Demographics
NPI:1649725094
Name:FLEAGLE, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:FLEAGLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 STONE WAY N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-8014
Mailing Address - Country:US
Mailing Address - Phone:206-545-2436
Mailing Address - Fax:206-632-2437
Practice Address - Street 1:4120 STONE WAY N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-8014
Practice Address - Country:US
Practice Address - Phone:206-545-2436
Practice Address - Fax:206-632-2437
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60262098101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor