=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881717726
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARLENE MARIE RICHARDSON LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 377 WEST WATER ST
-----------------------------------------------------
City | STAYTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97383-4018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-979-4655
-----------------------------------------------------
Fax | 503-967-3052
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 377 W WATER ST
-----------------------------------------------------
City | STAYTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97383-2231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-979-4655
-----------------------------------------------------
Fax | 503-767-3052
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | C7118
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------