Healthcare Provider Details

I. General information

NPI: 1487191797
Provider Name (Legal Business Name): LIFESPAN PSYCHIATRIC CONSULTING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2017
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 NE 3RD ST
GRESHAM OR
97030-7418
US

IV. Provider business mailing address

955 NE 3RD ST
GRESHAM OR
97030-7418
US

V. Phone/Fax

Practice location:
  • Phone: 503-491-5896
  • Fax: 888-972-9783
Mailing address:
  • Phone: 503-491-5896
  • Fax: 888-972-9783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number20070075NP
License Number StateOR

VIII. Authorized Official

Name: MR. ANDREW VILIUS
Title or Position: OWNER / PRINCIPAL
Credential: PMHNP
Phone: 503-491-5896