Provider Demographics
NPI:1326474800
Name:ULLOA, LAURA MARIE (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:MARIE
Last Name:ULLOA
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:MARIE
Other - Last Name:MAITREJEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSWA
Mailing Address - Street 1:931 CHEVY WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4127
Mailing Address - Country:US
Mailing Address - Phone:541-535-6239
Mailing Address - Fax:
Practice Address - Street 1:931 CHEVY WAY
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-4127
Practice Address - Country:US
Practice Address - Phone:541-535-6239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL8473104100000X, 104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500718925Medicaid