Provider Demographics
NPI:1801923396
Name:HAVSTAD, LAURA JEAN (PHD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:JEAN
Last Name:HAVSTAD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 PLEASANT HILL AVE N
Mailing Address - Street 2:370
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-3164
Mailing Address - Country:US
Mailing Address - Phone:707-823-1848
Mailing Address - Fax:707-823-1848
Practice Address - Street 1:120 PLEASANT HILL AVE N
Practice Address - Street 2:370
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-3164
Practice Address - Country:US
Practice Address - Phone:707-823-1848
Practice Address - Fax:707-823-1848
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 6690103TB0200X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent