1235120817 NPI number — DR. LIANNE CAROLE LENNERT PSYD

Table of content: DR. LIANNE CAROLE LENNERT PSYD (NPI 1235120817)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235120817 NPI number — DR. LIANNE CAROLE LENNERT PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LENNERT
Provider First Name:
LIANNE
Provider Middle Name:
CAROLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
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:
1235120817
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
915 NW 87TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97229-6462
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-203-6845
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4900 SW GRIFFITH DR
Provider Second Line Business Practice Location Address:
STE 235
Provider Business Practice Location Address City Name:
BEAVERTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97005-5607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-539-4654
Provider Business Practice Location Address Fax Number:
503-641-1601
Provider Enumeration Date:
11/02/2005

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: 103TC0700X , with the licence number:  1538 , 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)

  • Identifier: 213440 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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