Provider Demographics
NPI:1861813107
Name:WELTON, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WELTON
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 1:1200 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-6002
Mailing Address - Country:US
Mailing Address - Phone:217-254-6251
Mailing Address - Fax:
Practice Address - Street 1:1200 S 9TH ST
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-6002
Practice Address - Country:US
Practice Address - Phone:217-238-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-03
Last Update Date:2014-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242002672235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist