Provider Demographics
NPI:1376645028
Name:MAISLEN, MEREDITH (MED,LCSW)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:MAISLEN
Suffix:
Gender:F
Credentials:MED,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1305
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-0101
Mailing Address - Country:US
Mailing Address - Phone:541-265-3573
Mailing Address - Fax:
Practice Address - Street 1:928 SW HURBERT ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-4715
Practice Address - Country:US
Practice Address - Phone:541-265-3573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLCSW 06901041C0700X
CALCS136781041C0700X
NY021280-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR092835Medicaid
ORR0000TLCTTMedicare PIN
OR092835Medicaid