Provider Demographics
NPI:1144389354
Name:VANBEUZEKOM, LAUREL LEE (LMFT)
Entity Type:Individual
Prefix:MS
First Name:LAUREL
Middle Name:LEE
Last Name:VANBEUZEKOM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3167 W LORRAINE AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2439
Mailing Address - Country:US
Mailing Address - Phone:541-580-7893
Mailing Address - Fax:541-957-0191
Practice Address - Street 1:1299 NW ELLAN ST STE 3
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-2031
Practice Address - Country:US
Practice Address - Phone:541-580-7893
Practice Address - Fax:541-957-0191
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT0440106H00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR165772Medicaid
OR500688893Medicaid