Provider Demographics
NPI:1861170268
Name:FOSTER, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:FOSTER
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 1:18846 W WOODDALE TRL
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-6752
Mailing Address - Country:US
Mailing Address - Phone:317-480-6360
Mailing Address - Fax:
Practice Address - Street 1:545 N BENJAMIN LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9623
Practice Address - Country:US
Practice Address - Phone:317-480-6360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.110795104100000X
ID43756104100000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker