Provider Demographics
NPI:1306275847
Name:WHITE, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:255 LANCASTER DR NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-5155
Mailing Address - Country:US
Mailing Address - Phone:503-364-0775
Mailing Address - Fax:503-576-8400
Practice Address - Street 1:255 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-5155
Practice Address - Country:US
Practice Address - Phone:503-364-0775
Practice Address - Fax:503-576-8400
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2469103T00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1306275847Medicaid
ORR177723OtherMEDICARE
ORR177722OtherMEDICARE