Basic Information
Provider Information | |||||||||
NPI: | 1184216079 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GEARHEARD COLINDRES | ||||||||
FirstName: | JULILA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | COLINDRES | ||||||||
OtherFirstName: | JEWEL | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 621 SE 155TH AVE | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972333144 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5037540383 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2507 CHRISTIE DRIVE | ||||||||
Address2: |   | ||||||||
City: | LAKE OSWEGO | ||||||||
State: | OR | ||||||||
PostalCode: | 97034 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5036353416 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/11/2021 | ||||||||
LastUpdateDate: | 02/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.