Healthcare Provider Details

I. General information

NPI: 1457701724
Provider Name (Legal Business Name): DENIELLE EDLUND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22018 S CENTRAL POINT RD
CANBY OR
97013-8705
US

IV. Provider business mailing address

4622 SW GREENHILLS WAY
PORTLAND OR
97221-3274
US

V. Phone/Fax

Practice location:
  • Phone: 503-221-4531
  • Fax:
Mailing address:
  • Phone: 339-236-0956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: