Provider Demographics
NPI:1538054143
Name:VILLAGOMEZ, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:VILLAGOMEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5631 SE LOGUS RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-4228
Mailing Address - Country:US
Mailing Address - Phone:831-809-8634
Mailing Address - Fax:
Practice Address - Street 1:501 N DIXON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1804
Practice Address - Country:US
Practice Address - Phone:503-916-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-12
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR528569103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool