Healthcare Provider Details

I. General information

NPI: 1538910500
Provider Name (Legal Business Name): MRS. KYLIE DIERINGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2024
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1584 NE 8TH ST STE 200
GRESHAM OR
97030-5746
US

IV. Provider business mailing address

1584 NE 8TH ST STE 200
GRESHAM OR
97030-5746
US

V. Phone/Fax

Practice location:
  • Phone: 971-421-8696
  • Fax:
Mailing address:
  • Phone: 971-421-8696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberR7369
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: