Basic Information
| Provider Information | |||||||||
| NPI: | 1548629116 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORTUNE | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | RAE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CAC/CM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1121 | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974700254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416722691 | ||||||||
| FaxNumber: | 5416735642 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 VIRGINIA AVE #201 | ||||||||
| Address2: | |||||||||
| City: | NORTH BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974592709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417510357 | ||||||||
| FaxNumber: | 5417519985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2016 | ||||||||
| LastUpdateDate: | 02/11/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.