Provider Demographics
NPI:1174030779
Name:PRIEB, ALISSA
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:
Last Name:PRIEB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8205 SPAIN RD NE STE 106
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3155
Mailing Address - Country:US
Mailing Address - Phone:505-856-0300
Mailing Address - Fax:
Practice Address - Street 1:1705 CENTENNIAL BLVD STE 2
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-3320
Practice Address - Country:US
Practice Address - Phone:541-818-0009
Practice Address - Fax:417-806-9675
Is Sole Proprietor?:No
Enumeration Date:2018-01-04
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC6264101YM0800X
ORR6472101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500791921Medicaid