Provider Demographics
NPI:1144593112
Name:BLACK, LAURIE CAROL (QMHA)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:CAROL
Last Name:BLACK
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:CAROL
Other - Last Name:ANGUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:QMHA
Mailing Address - Street 1:1255 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3570
Mailing Address - Country:US
Mailing Address - Phone:541-687-6983
Mailing Address - Fax:541-687-2063
Practice Address - Street 1:1255 PEARL ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3570
Practice Address - Country:US
Practice Address - Phone:541-687-6983
Practice Address - Fax:541-687-2063
Is Sole Proprietor?:No
Enumeration Date:2012-02-21
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health