Healthcare Provider Details

I. General information

NPI: 1588992028
Provider Name (Legal Business Name): LAUREL JOHNSON CSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2009
Last Update Date: 01/13/2026
Certification Date: 01/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2154 NE BROADWAY ST STE 110
PORTLAND OR
97232-1561
US

IV. Provider business mailing address

2154 NE BROADWAY ST STE 110
PORTLAND OR
97232-1561
US

V. Phone/Fax

Practice location:
  • Phone: 503-473-2081
  • Fax:
Mailing address:
  • Phone: 503-473-2081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberA16501
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: