Basic Information
| Provider Information | |||||||||
| NPI: | 1902264112 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDRADE-BAHRE | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | ANN | ||||||||
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| OtherLastName: | ANDRADE | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3587 HEATHROW WAY | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418588170 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 17710 NE HALSEY ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972306734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712933468 | ||||||||
| FaxNumber: | 9712933469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2016 | ||||||||
| LastUpdateDate: | 11/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.