Basic Information
| Provider Information | |||||||||
| NPI: | 1821424326 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PFEIFFER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | LYLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1027 E BURNSIDE ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032398400 | ||||||||
| FaxNumber: | 5032398407 | ||||||||
| Practice Location | |||||||||
| Address1: | 10362 SW MCDONALD ST | ||||||||
| Address2: | |||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972244863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036240312 | ||||||||
| FaxNumber: | 5036393973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2013 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/14/2021 | ||||||||
| NPIReactivationDate: | 03/02/2021 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | Y | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.