Basic Information
| Provider Information | |||||||||
| NPI: | 1770140881 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALI | ||||||||
| FirstName: | AYESHA | ||||||||
| MiddleName: | MOHAMED | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2577 NE COURTNEY DR | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977017752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413227500 | ||||||||
| FaxNumber: | 5413227565 | ||||||||
| Practice Location | |||||||||
| Address1: | 63311 JAMISON ST | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977038288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413227500 | ||||||||
| FaxNumber: | 5413227565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2019 | ||||||||
| LastUpdateDate: | 05/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 084586 | OR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | L10972 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | STB-A-10184107 | 01 | OR | CERTIFIED ASSOCIATE SEX OFFENDER THERAPIST | OTHER |