Provider Demographics
NPI:1326337965
Name:SHANK, LAURA K (PSYD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:K
Last Name:SHANK
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:K
Other - Last Name:SHANK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:PO BOX 5579
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-5579
Mailing Address - Country:US
Mailing Address - Phone:541-706-2768
Mailing Address - Fax:541-706-4760
Practice Address - Street 1:2542 NE COURTNEY DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7685
Practice Address - Country:US
Practice Address - Phone:541-706-2768
Practice Address - Fax:541-706-4760
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2915-57103TC0700X
OR100250103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2915-57OtherLICENSE