Basic Information
| Provider Information | |||||||||
| NPI: | 1528363876 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALSTEAD | ||||||||
| FirstName: | DZENANA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11211 SE 82ND AVE STE 0 | ||||||||
| Address2: | |||||||||
| City: | HAPPY VALLEY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970867641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037226200 | ||||||||
| FaxNumber: | 5037226545 | ||||||||
| Practice Location | |||||||||
| Address1: | 11211 SE 82ND AVE STE 0 | ||||||||
| Address2: | |||||||||
| City: | HAPPY VALLEY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970867641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037226200 | ||||||||
| FaxNumber: | 5037226545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2011 | ||||||||
| LastUpdateDate: | 08/16/2017 | ||||||||
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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 | 101YM0800X | C3558 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 500678475 | 05 | OR | MEDICAID |