Provider Demographics
NPI:1871960864
Name:EASTWICK, LAURA MARTINA (LICSW, LCSW)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MARTINA
Last Name:EASTWICK
Suffix:
Gender:F
Credentials:LICSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 HARRIS ST
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-4512
Mailing Address - Country:US
Mailing Address - Phone:617-510-0025
Mailing Address - Fax:
Practice Address - Street 1:720 14TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2315
Practice Address - Country:US
Practice Address - Phone:360-423-0203
Practice Address - Fax:360-577-0269
Is Sole Proprietor?:No
Enumeration Date:2015-08-26
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL113281041C0700X
WALW613075951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2140834Medicaid