Provider Demographics
NPI:1992023121
Name:GOREN, LAURIE (PSYD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:GOREN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 LINCOLN AVE
Mailing Address - Street 2:SUITE 102-B
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2120
Mailing Address - Country:US
Mailing Address - Phone:415-460-1330
Mailing Address - Fax:
Practice Address - Street 1:1330 LINCOLN AVE
Practice Address - Street 2:SUITE 102-B
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2120
Practice Address - Country:US
Practice Address - Phone:415-460-1330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-12
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 28327103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical