Basic Information
| Provider Information | |||||||||
| NPI: | 1770942724 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIAL | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CREDLE | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 504 VILLA RD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | NEWBERG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971321851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035384874 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 504 VILLA RD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | NEWBERG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971321851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035384874 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2016 | ||||||||
| LastUpdateDate: | 02/18/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.