Provider Demographics
NPI:1639208234
Name:GANBERG, LAURIE (MSW, LICSW)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:
Last Name:GANBERG
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:MS
Other - First Name:LAURIE
Other - Middle Name:
Other - Last Name:GUTIERREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10740 MERIDIAN AVE N STE 104
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-9010
Mailing Address - Country:US
Mailing Address - Phone:425-434-5594
Mailing Address - Fax:
Practice Address - Street 1:10740 MERIDIAN AVE N STE 104
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-9010
Practice Address - Country:US
Practice Address - Phone:425-434-5594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1150741041C0700X
WALW606733201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical