Basic Information
| Provider Information | |||||||||
| NPI: | 1063884856 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | LOLA | ||||||||
| MiddleName: | AMINOVA | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | AMINOVA | ||||||||
| OtherFirstName: | LOLA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2214 LLOYD CTR | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972321311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034944222 | ||||||||
| FaxNumber: | 5034946143 | ||||||||
| Practice Location | |||||||||
| Address1: | 2214 LLOYD CTR | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972321311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034944222 | ||||||||
| FaxNumber: | 5034946143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2015 | ||||||||
| LastUpdateDate: | 05/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | L10543 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.