Provider Demographics
NPI:1285002220
Name:HORTON, LYNNDIE M (CADC I/QMHA)
Entity Type:Individual
Prefix:
First Name:LYNNDIE
Middle Name:M
Last Name:HORTON
Suffix:
Gender:F
Credentials:CADC I/QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 NW WILSON ST APT 5
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-1978
Mailing Address - Country:US
Mailing Address - Phone:503-442-8741
Mailing Address - Fax:
Practice Address - Street 1:1631 SW COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-6025
Practice Address - Country:US
Practice Address - Phone:503-231-2641
Practice Address - Fax:503-231-1654
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
OR12-03-15101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500717550Medicaid
OR500699933Medicaid