Provider Demographics
NPI:1073939211
Name:BIRNDORF, LARISSA (MSW, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:BIRNDORF
Suffix:
Gender:F
Credentials:MSW, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2873 NW RALEIGH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2464
Mailing Address - Country:US
Mailing Address - Phone:503-679-7824
Mailing Address - Fax:
Practice Address - Street 1:2701 NW VAUGHN ST STE 470
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5326
Practice Address - Country:US
Practice Address - Phone:503-719-4648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-12
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201393260RN163W00000X
OR201504586NP-PP363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1457856148OtherGROUP NPI