Healthcare Provider Details

I. General information

NPI: 1528290400
Provider Name (Legal Business Name): LAURA MAE VAN WAARDENBURG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2009
Last Update Date: 05/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19343 HIGHWAY 12
SONOMA CA
95476-5445
US

IV. Provider business mailing address

400 E THOMSON AVE
SONOMA CA
95476-8442
US

V. Phone/Fax

Practice location:
  • Phone: 415-596-2023
  • Fax:
Mailing address:
  • Phone: 415-596-2023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number29431
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier29431
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerCALIFORNIA BOARD OF BEHAVIORAL SCIENCES, LICENSED CLINICAL SOCIAL WORKER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: