Provider Demographics
NPI:1528290400
Name:VAN WAARDENBURG, LAURA MAE (LCSW)
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:MAE
Last Name:VAN WAARDENBURG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E THOMSON AVE
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-8442
Mailing Address - Country:US
Mailing Address - Phone:415-596-2023
Mailing Address - Fax:
Practice Address - Street 1:19343 HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-5445
Practice Address - Country:US
Practice Address - Phone:415-596-2023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-11
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA294311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA29431OtherCALIFORNIA BOARD OF BEHAVIORAL SCIENCES, LICENSED CLINICAL SOCIAL WORKER