Healthcare Provider Details

I. General information

NPI: 1972284560
Provider Name (Legal Business Name): LAUREL MARIE COLEMAN WENDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 WEEOT WAY
ARCATA CA
95521-4734
US

IV. Provider business mailing address

1171 TILLEY CT # A
ARCATA CA
95521-6720
US

V. Phone/Fax

Practice location:
  • Phone: 707-258-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW122985
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW122985
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: