Basic Information
| Provider Information | |||||||||
| NPI: | 1295043982 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFEWORKS NORTHWEST | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5415 SW WESTGATE DRIVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972212406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036453581 | ||||||||
| FaxNumber: | 5036298517 | ||||||||
| Practice Location | |||||||||
| Address1: | 5415 SW WESTGATE DRIVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972212406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036453581 | ||||||||
| FaxNumber: | 5036298517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2010 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MONNAT | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5036453581 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MA, LPC, CADCIII | ||||||||
| NPICertificationDate: | 03/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311ZA0620X | Y | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
ID Information
| ID | Type | State | Issuer | Description | 500621571 | 05 | OR | MEDICAID |