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General NPI Number Information
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NPI Number | 1366308785
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Entity Type | Organization
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Legal Business Name | LAKESIDE SERENITY PSYCHIATRY, LLC
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Dates
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Enumeration Date | 12/30/2025
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Last Update Date | 12/30/2025
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Provider Practice Location Address
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Address Line | 5441 S.MACCADAN AVE 8160
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City | PORTLAND
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State | OR
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Zip | 97239
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Country | US
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Telephone | 917-265-9614
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Fax |
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Provider Business Mailing Address
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Address Line | 821 KENDRA DR
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City | TEMPLE
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State | TX
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Zip | 76502-5878
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Country | US
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Telephone | 917-265-9611
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Fax | 917-265-9614
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Authorized Official
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Title or Position | OWNER
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Name | DALLAS UPCHURCH
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Credential | PMHNP-BC
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Telephone | 917-265-9614
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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