Provider Demographics
NPI:1578786505
Name:PARK, LAURA JO (LMFT)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:JO
Last Name:PARK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:JO
Other - Last Name:POMEROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 2046
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208
Mailing Address - Country:US
Mailing Address - Phone:503-388-8898
Mailing Address - Fax:209-956-4245
Practice Address - Street 1:2311 E. BURNSIDE ST.
Practice Address - Street 2:STE 102
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214
Practice Address - Country:US
Practice Address - Phone:503-388-8898
Practice Address - Fax:209-956-4245
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 39359101YM0800X
ORT0702106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health