1407027758 NPI number — MS. DEBRA LYNN GREENHOLTZ-CARRILLO MS CCC SCP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407027758 NPI number — MS. DEBRA LYNN GREENHOLTZ-CARRILLO MS CCC SCP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREENHOLTZ-CARRILLO
Provider First Name:
DEBRA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS CCC SCP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407027758
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17845 NW SEDGEWICK CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAVERTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-645-0901
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 NE PARK PLAZA DR
Provider Second Line Business Practice Location Address:
SUITE 246
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98684
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-696-2070
Provider Business Practice Location Address Fax Number:
360-737-0200
Provider Enumeration Date:
03/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  13045 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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