Provider Demographics
NPI:1083167159
Name:EMMONS, LYNN ALICE (LCSW, RN, CADCI)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:ALICE
Last Name:EMMONS
Suffix:
Gender:F
Credentials:LCSW, RN, CADCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6305 NE PRESCOTT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-3247
Mailing Address - Country:US
Mailing Address - Phone:503-522-9655
Mailing Address - Fax:
Practice Address - Street 1:5128 NE 42ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97218-1506
Practice Address - Country:US
Practice Address - Phone:971-930-2586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12-09-11101YA0400X
ORL66591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)