Provider Demographics
NPI:1114029774
Name:QUEEN, LORI (PHD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:QUEEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7505 SW BEVELAND RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8682
Mailing Address - Country:US
Mailing Address - Phone:503-639-6843
Mailing Address - Fax:
Practice Address - Street 1:7505 SW BEVELAND RD
Practice Address - Street 2:SUITE 204
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8682
Practice Address - Country:US
Practice Address - Phone:503-639-6843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1114103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical