Provider Demographics
NPI:1235545443
Name:LAWRENCE, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:LAWRENCE
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 1:1900 NE 3RD ST
Mailing Address - Street 2:STE 106 PBM 3041
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3889
Mailing Address - Country:US
Mailing Address - Phone:541-777-7230
Mailing Address - Fax:
Practice Address - Street 1:8180 SW CRATER LOOP RD
Practice Address - Street 2:
Practice Address - City:TERREBONNE
Practice Address - State:OR
Practice Address - Zip Code:97760-9004
Practice Address - Country:US
Practice Address - Phone:541-777-7230
Practice Address - Fax:541-923-7139
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-08
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6785225700000X
ORC4474101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist