Basic Information
| Provider Information | |||||||||
| NPI: | 1184778417 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAISCH | ||||||||
| FirstName: | DEANNE | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14600 NW CORNELL RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972295442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036453581 | ||||||||
| FaxNumber: | 5035909605 | ||||||||
| Practice Location | |||||||||
| Address1: | 10202 SE 32ND AVE | ||||||||
| Address2: | STE. 504 | ||||||||
| City: | MILWAUKIE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972223610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036453581 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 01/28/2012 | ||||||||
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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 | 101Y00000X | 2972 | NE | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 47037660631 | 05 | NE | MEDICAID |