Provider Demographics
NPI:1629213525
Name:CALDWELL, LAURA R
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:R
Last Name:CALDWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:R
Other - Last Name:JACOBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 E. EVERGREEN BLVD.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660
Mailing Address - Country:US
Mailing Address - Phone:360-694-4739
Mailing Address - Fax:360-573-9463
Practice Address - Street 1:400 E. EVERGREEN BLVD.
Practice Address - Street 2:SUITE 100
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660
Practice Address - Country:US
Practice Address - Phone:360-694-4739
Practice Address - Fax:360-573-9463
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-05
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00004062101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health