Provider Demographics
NPI:1235148610
Name:MCQUEEN, LILA
Entity Type:Individual
Prefix:MRS
First Name:LILA
Middle Name:
Last Name:MCQUEEN
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 1:41441 MCQUEEN DR
Mailing Address - Street 2:
Mailing Address - City:SWEET HOME
Mailing Address - State:OR
Mailing Address - Zip Code:97386-9661
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1711 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-3111
Practice Address - Country:US
Practice Address - Phone:541-259-5400
Practice Address - Fax:541-259-5499
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR666103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR068WFBJRAMedicare ID - Type Unspecified