Healthcare Provider Details

I. General information

NPI: 1861034951
Provider Name (Legal Business Name): LIESL FARNSWORTH, PHD, LPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2019
Last Update Date: 05/07/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

552 NW SAGINAW AVE # 2
BEND OR
97703-1120
US

IV. Provider business mailing address

552 NW SAGINAW AVE # 2
BEND OR
97703-1120
US

V. Phone/Fax

Practice location:
  • Phone: 541-388-1261
  • Fax:
Mailing address:
  • Phone: 541-388-1261
  • Fax: 541-306-4577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. LIESL FARNSWORTH
Title or Position: OWNER
Credential: PHD, LPC
Phone: 541-388-1261