Provider Demographics
NPI:1023027877
Name:BARDELL, LARRY LEE (MN, PMHNP)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:LEE
Last Name:BARDELL
Suffix:
Gender:M
Credentials:MN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 NW SPRINGHILL DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-1587
Mailing Address - Country:US
Mailing Address - Phone:541-928-0747
Mailing Address - Fax:
Practice Address - Street 1:1660 OAK ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-6942
Practice Address - Country:US
Practice Address - Phone:503-316-8817
Practice Address - Fax:503-316-9037
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR077038453N6 PMHNP-PP163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR077038453N6 PMHNP-PPOtherSTATE BOARD OF NURSING
MB0143228OtherDEA REGISTRATION