Provider Demographics
NPI:1871146316
Name:KLOSS, LORI G
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:G
Last Name:KLOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4585 SW 185TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97078-1557
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2225 PACIFIC BLVD SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-7907
Practice Address - Country:US
Practice Address - Phone:541-321-2278
Practice Address - Fax:541-249-8826
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC7299101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500771153Medicaid