Basic Information
| Provider Information | |||||||||
| NPI: | 1588338701 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCINTOSH | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | DAWN | ||||||||
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| Credential: | QMHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4080 REED RD SE STE 150 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973021335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035811732 | ||||||||
| FaxNumber: | 5033634607 | ||||||||
| Practice Location | |||||||||
| Address1: | 4080 REED RD SE STE 150 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973021335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035811732 | ||||||||
| FaxNumber: | 5033634607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2021 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.