MEDICARE: LAURA KS WILSON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	L5438	OR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R167058	OTHER		MEDICARE PTAN

General Provider Information

NPI Number	:	1457654360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA KS WILSON LCSW

Provider Business Mailing Address
First Line	:	360 E 10TH AVE STE 400
Second Line	:
City	:	EUGENE
State	:	OR
Zip	:	97401-3273
Country	:	US
Telephone Number	:	541-687-6983
Fax Number	:

Provider Business Practice Location Address
First Line	:	360 E 10TH AVE STE 400
Second Line	:
City	:	EUGENE
State	:	OR
Zip	:	97401-3273
Country	:	US
Telephone Number	:	541-687-6983
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2010
Last Update Date	:	03/02/2023

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