Healthcare Provider Details

I. General information

NPI: 1225402449
Provider Name (Legal Business Name): MRS. LAURIE B FIELDMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAURIE B FIELDMAN LCSW

II. Dates (important events)

Enumeration Date: 11/27/2015
Last Update Date: 01/21/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 W SPERRY ST
HEPPNER OR
97836
US

IV. Provider business mailing address

1025 POTOMAC CT
GRAYSLAKE IL
60030-7921
US

V. Phone/Fax

Practice location:
  • Phone: 541-676-9161
  • Fax: 541-676-5662
Mailing address:
  • Phone: 847-274-6582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149006769
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL12054
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: