Healthcare Provider Details

I. General information

NPI: 1821302977
Provider Name (Legal Business Name): HEATHER DANIELLE LARA HEATHER BENNETT, M.A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HEATHER BENNETT

II. Dates (important events)

Enumeration Date: 07/31/2010
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 N MAIN AVE STE 201D
GRESHAM OR
97030-7242
US

IV. Provider business mailing address

320 N MAIN AVE STE 201D
GRESHAM OR
97030-7242
US

V. Phone/Fax

Practice location:
  • Phone: 503-974-8310
  • Fax:
Mailing address:
  • Phone: 503-974-8310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberREGISTERED INTERN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: