Basic Information
| Provider Information | |||||||||
| NPI: | 1144415191 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EQUALL LACOMBE | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | MAE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 290 MOYER LN NW | ||||||||
| Address2: | PO BOX 5193 | ||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973043822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033708990 | ||||||||
| FaxNumber: | 5033634214 | ||||||||
| Practice Location | |||||||||
| Address1: | 290 MOYER LN NW | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973043822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033708990 | ||||||||
| FaxNumber: | 5033634214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2007 | ||||||||
| LastUpdateDate: | 02/26/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 195164 | 05 | OR | MEDICAID |