Basic Information
Provider Information | |||||||||
NPI: | 1073791497 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FOLIANO | ||||||||
FirstName: | JANET | ||||||||
MiddleName: | SUE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSYD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5579 | ||||||||
Address2: |   | ||||||||
City: | BEND | ||||||||
State: | OR | ||||||||
PostalCode: | 977085579 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5417062768 | ||||||||
FaxNumber: | 5417064760 | ||||||||
Practice Location | |||||||||
Address1: | 61250 SE COOMBS PL | ||||||||
Address2: |   | ||||||||
City: | BEND | ||||||||
State: | OR | ||||||||
PostalCode: | 977023704 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5417065935 | ||||||||
FaxNumber: | 5417065936 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/07/2008 | ||||||||
LastUpdateDate: | 04/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 3427 | CO | N |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | 100240 | OR | Y |   | Behavioral Health & Social Service Providers | Psychologist |   |
ID Information
ID | Type | State | Issuer | Description | 500668080 | 05 | OR |   | MEDICAID |