Healthcare Provider Details

I. General information

NPI: 1689384711
Provider Name (Legal Business Name): LIDIYA KHOROSHENKIKH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2022
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date: 12/30/2025
Reactivation Date: 03/18/2026

III. Provider practice location address

304 NE HOOD AVE
GRESHAM OR
97030-7450
US

IV. Provider business mailing address

304 NE HOOD AVE
GRESHAM OR
97030-7450
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-1333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: