Basic Information
| Provider Information | |||||||||
| NPI: | 1225637671 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STURDIVANT | ||||||||
| FirstName: | LISA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21900 WILLAMETTE DR STE 202 | ||||||||
| Address2: | |||||||||
| City: | WEST LINN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970683284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036530631 | ||||||||
| FaxNumber: | 5036531464 | ||||||||
| Practice Location | |||||||||
| Address1: | 21900 WILLAMETTE DR STE 202 | ||||||||
| Address2: | |||||||||
| City: | WEST LINN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970683284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037899733 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2020 | ||||||||
| LastUpdateDate: | 04/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | R4829 | OR | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | R6173 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.