Provider Demographics
NPI:1376878314
Name:GRISANTI, LAURENCE (PMHNP)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:
Last Name:GRISANTI
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 SW TAYLOR ST
Mailing Address - Street 2:SUITE 700
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2512
Mailing Address - Country:US
Mailing Address - Phone:503-395-8326
Mailing Address - Fax:
Practice Address - Street 1:522 SW 5TH AVE
Practice Address - Street 2:SUITE 1125
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-2133
Practice Address - Country:US
Practice Address - Phone:503-395-8326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-08
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201050181NP163WP0808X
OR200640886 RN163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR123190Medicaid