Provider Demographics
NPI:1770020968
Name:SPROUSE, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:SPROUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3876 BEVERLY AVE NE
Mailing Address - Street 2:BLDG G
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1319
Mailing Address - Country:US
Mailing Address - Phone:503-576-4536
Mailing Address - Fax:
Practice Address - Street 1:3876 BEVERLY AVE NE
Practice Address - Street 2:BLDG G
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1319
Practice Address - Country:US
Practice Address - Phone:503-576-4536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator