Provider Demographics
NPI:1457654360
Name:WILSON, LAURA KS (LCSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:KS
Last Name:WILSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:K
Other - Last Name:SILVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:360 E 10TH AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-3273
Mailing Address - Country:US
Mailing Address - Phone:541-687-6983
Mailing Address - Fax:
Practice Address - Street 1:360 E 10TH AVE STE 400
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3273
Practice Address - Country:US
Practice Address - Phone:541-687-6983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-15
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL54381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
R167058OtherMEDICARE PTAN