Provider Demographics
NPI:1235120817
Name:LENNERT, LIANNE CAROLE (PSYD)
Entity type:Individual
Prefix:DR
First Name:LIANNE
Middle Name:CAROLE
Last Name:LENNERT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 NW 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-6462
Mailing Address - Country:US
Mailing Address - Phone:503-203-6845
Mailing Address - Fax:
Practice Address - Street 1:4900 SW GRIFFITH DR
Practice Address - Street 2:STE 235
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-5607
Practice Address - Country:US
Practice Address - Phone:503-539-4654
Practice Address - Fax:503-641-1601
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1538103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213440Medicaid