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General NPI Number Information
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NPI Number | 1538477500
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Entity Type | Organization
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Legal Business Name | LIFE BALANCE NORTHWEST, LLC
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Dates
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Enumeration Date | 09/23/2010
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Last Update Date | 10/17/2016
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Provider Practice Location Address
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Address Line | 1595 HOLLY ST
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City | WEST LINN
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State | OR
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Zip | 97068-3326
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Country | US
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Telephone | 503-344-6211
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Fax | 503-344-6991
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Provider Business Mailing Address
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Address Line | 333 S STATE ST V137
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City | LAKE OSWEGO
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State | OR
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Zip | 97034-5052
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Country | US
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Telephone | 503-344-6211
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Fax | 503-344-6991
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Authorized Official
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Title or Position | PSYCHIATRIST
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Name | ANN MARIE CHILDERS
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Credential | MD
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Telephone | 503-344-6211
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number | MD19493
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License Number State | OR
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