Provider Demographics
NPI:1083141444
Name:KERRIDGE, LAURIE (MA, LPC)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:KERRIDGE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 KEN PRATT BLVD STE 120-40
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-8993
Mailing Address - Country:US
Mailing Address - Phone:858-449-1589
Mailing Address - Fax:720-419-0228
Practice Address - Street 1:7175 SW BEVELAND RD STE 205
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-8665
Practice Address - Country:US
Practice Address - Phone:858-449-1589
Practice Address - Fax:720-419-0228
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-16
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61314459101YP2500X
COLPC.0017006101YP2500X
ORC5724101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500805498Medicaid
CO9000210170Medicaid