Provider Demographics
NPI:1245674829
Name:HAVENS, LAURA J (LMFT LMHC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:HAVENS
Suffix:
Gender:F
Credentials:LMFT LMHC
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:J
Other - Last Name:COSTELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT LMHC
Mailing Address - Street 1:313 EAST 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362
Mailing Address - Country:US
Mailing Address - Phone:360-460-0217
Mailing Address - Fax:
Practice Address - Street 1:104 NORTH LAUREL ST SUITE 114
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362
Practice Address - Country:US
Practice Address - Phone:360-460-0217
Practice Address - Fax:360-504-3699
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-25
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60527932101YM0800X
LF60805478106H00000X
WALMFTLF60805478101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2047063Medicaid