Healthcare Provider Details

I. General information

NPI: 1235120817
Provider Name (Legal Business Name): LIANNE CAROLE LENNERT PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 SW GRIFFITH DR STE 235
BEAVERTON OR
97005-5607
US

IV. Provider business mailing address

915 NW 87TH AVE
PORTLAND OR
97229-6462
US

V. Phone/Fax

Practice location:
  • Phone: 503-539-4654
  • Fax: 503-641-1601
Mailing address:
  • Phone: 503-203-6845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1538
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: