Provider Demographics
NPI:1043422413
Name:BENNETT, LAURA SHEFFIELD (PHD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:SHEFFIELD
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8401 NE HALSEY ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-5670
Mailing Address - Country:US
Mailing Address - Phone:503-977-0400
Mailing Address - Fax:208-248-0977
Practice Address - Street 1:8401 NE HALSEY ST
Practice Address - Street 2:SUITE 203
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-5670
Practice Address - Country:US
Practice Address - Phone:503-977-0400
Practice Address - Fax:208-248-0977
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-05
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1678103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR026862OtherOMAP NUMBER