Provider Demographics
NPI:1205818580
Name:HEESACKER, LAURA N (LCSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:N
Last Name:HEESACKER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 503010
Mailing Address - Street 2:
Mailing Address - City:WHITE CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97503-0813
Mailing Address - Country:US
Mailing Address - Phone:541-941-7792
Mailing Address - Fax:503-419-4662
Practice Address - Street 1:385 E MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1834
Practice Address - Country:US
Practice Address - Phone:541-488-0830
Practice Address - Fax:503-419-4662
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL41101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR227698Medicaid