Basic Information
| Provider Information | |||||||||
| NPI: | 1558676643 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SNOW | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THOMPSON | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PSYD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| 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: | 5036530631 | ||||||||
| FaxNumber: | 5036531464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2010 | ||||||||
| LastUpdateDate: | 10/30/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| 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 | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC0700X | 3137 | OR | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.