Healthcare Provider Details

I. General information

NPI: 1760394175
Provider Name (Legal Business Name): LILIAN JUDITH AQUINO GONZALEZ
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 SE 102ND AVE
PORTLAND OR
97216-2700
US

IV. Provider business mailing address

121 NW EVERETT ST
PORTLAND OR
97209-4049
US

V. Phone/Fax

Practice location:
  • Phone: 503-546-9975
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number26-QMHA-R-8961
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: