Healthcare Provider Details

I. General information

NPI: 1144389354
Provider Name (Legal Business Name): LAUREL LEE VANBEUZEKOM LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 06/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1299 NW ELLAN ST STE 3
ROSEBURG OR
97470-2031
US

IV. Provider business mailing address

3167 W LORRAINE AVE
ROSEBURG OR
97471-2439
US

V. Phone/Fax

Practice location:
  • Phone: 541-580-7893
  • Fax: 541-957-0191
Mailing address:
  • Phone: 541-580-7893
  • Fax: 541-957-0191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT0440
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberT0440
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: