Basic Information
| Provider Information | |||||||||
| NPI: | 1467640847 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AZEN | ||||||||
| FirstName: | LIOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1245 EDGEWATER ST NW | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973044049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035885816 | ||||||||
| FaxNumber: | 5035885803 | ||||||||
| Practice Location | |||||||||
| Address1: | 1245 EDGEWATER ST NW | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973044049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035885816 | ||||||||
| FaxNumber: | 5035885803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2007 | ||||||||
| LastUpdateDate: | 07/25/2014 | ||||||||
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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 | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YP2500X | C3494 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.