Provider Demographics
NPI:1396876736
Name:FORTIN, LAURIE VIRGINIA (LCSW)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:VIRGINIA
Last Name:FORTIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:VIRGINIA
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:43135 CORTE ALMONTE
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-3632
Mailing Address - Country:US
Mailing Address - Phone:951-303-6794
Mailing Address - Fax:
Practice Address - Street 1:3020 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4223
Practice Address - Country:US
Practice Address - Phone:858-966-5980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 166991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical