Basic Information
| Provider Information | |||||||||
| NPI: | 1205239423 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUHLBAUER | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PMHNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TEFFT | ||||||||
| OtherFirstName: | LAURIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PMHNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1500 NW BETHANY BLVD | ||||||||
| Address2: | STE 320 | ||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035673260 | ||||||||
| FaxNumber: | 5035673264 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 NW BETHANY BLVD | ||||||||
| Address2: | STE 320 | ||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035673260 | ||||||||
| FaxNumber: | 5035673264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2014 | ||||||||
| LastUpdateDate: | 11/18/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 201406457RN | OR | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 363LP0808X | 201406458NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 164936 | 05 | OR | MEDICAID |