Basic Information
| Provider Information | |||||||||
| NPI: | 1407420110 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE LA LLAMA | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | ALYSSE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2014 SE 12TH AVE APT 307 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972145380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3187545009 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3990 COLLINS WAY STE 202 | ||||||||
| Address2: | |||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970353459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036752830 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2021 | ||||||||
| LastUpdateDate: | 05/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | L8586 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.