Provider Demographics
NPI:1912514852
Name:POORE, LAURIE ANN (PHD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:ANN
Last Name:POORE
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 1:218 W MAIN ST STE 202
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-7719
Mailing Address - Country:US
Mailing Address - Phone:714-573-4723
Mailing Address - Fax:
Practice Address - Street 1:218 W MAIN ST STE 202
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-7719
Practice Address - Country:US
Practice Address - Phone:714-573-4722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15972103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty