Basic Information
Provider Information
NPI: 1033556824
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MCLENDON
FirstName: DIANE
MiddleName: MARIE
NamePrefix:  
NameSuffix:  
Credential: QMHP
OtherOrganizationName:  
OtherOrganizationType:  
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OtherCredential:  
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Mailing Information
Address1: PO BOX 17818
Address2:  
City: SALEM
State: OR
PostalCode: 973057818
CountryCode: US
TelephoneNumber: 5033632021
FaxNumber:  
Practice Location
Address1: 3325 HAROLD DR NE
Address2:  
City: SALEM
State: OR
PostalCode: 973051339
CountryCode: US
TelephoneNumber: 5033632021
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/03/2013
LastUpdateDate: 07/09/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YA0400X  N Behavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
101YM0800X  N Behavioral Health & Social Service ProvidersCounselorMental Health
106H00000X  Y Behavioral Health & Social Service ProvidersMarriage & Family Therapist 

No ID Information.


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