Provider Demographics
NPI:1306394663
Name:LAUREN DEISENROTH PMHNP-BC LLC
Entity Type:Organization
Organization Name:LAUREN DEISENROTH PMHNP-BC LLC
Other - Org Name:LAUREN DEISENROTH PMHNP-BC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PMHNP, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:KATHERINE
Authorized Official - Last Name:DEISENROTH
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:918-520-3000
Mailing Address - Street 1:4511 SE HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3170
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4511 SE HAWTHORNE BLVD
Practice Address - Street 2:SUITE 215
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-3170
Practice Address - Country:US
Practice Address - Phone:503-224-6446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)