Provider Demographics
NPI:1477649192
Name:TAGUE, LAURIE ANNE (MFT)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:ANNE
Last Name:TAGUE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26741 PORTOLA PKWY STE 1E
Mailing Address - Street 2:
Mailing Address - City:FOOTHILL RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92610-1763
Mailing Address - Country:US
Mailing Address - Phone:714-343-8894
Mailing Address - Fax:
Practice Address - Street 1:14 CASINO RD
Practice Address - Street 2:
Practice Address - City:MARBLEHEAD
Practice Address - State:MA
Practice Address - Zip Code:01945-2823
Practice Address - Country:US
Practice Address - Phone:714-343-8894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 40998106H00000X
106H00000X
CA48881106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist