1578786505 NPI number — MS. LAURA JO PARK L.M.F.T.

Table of content: (NPI 1265457212)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578786505 NPI number — MS. LAURA JO PARK L.M.F.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PARK
Provider First Name:
LAURA
Provider Middle Name:
JO
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
L.M.F.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
POMEROY
Provider Other First Name:
LAURA
Provider Other Middle Name:
JO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578786505
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 2046
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-388-8898
Provider Business Mailing Address Fax Number:
209-956-4245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2311 E. BURNSIDE ST.
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-388-8898
Provider Business Practice Location Address Fax Number:
209-956-4245
Provider Enumeration Date:
04/10/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  IMF 39359 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: T0702 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)