Provider Demographics
NPI:1487232476
Name:GUIDICATTIEVANS, LORI L (CADC 1)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:L
Last Name:GUIDICATTIEVANS
Suffix:
Gender:F
Credentials:CADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 LIBERTY ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4143
Mailing Address - Country:US
Mailing Address - Phone:844-494-5105
Mailing Address - Fax:
Practice Address - Street 1:1160 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4143
Practice Address - Country:US
Practice Address - Phone:844-494-5105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21-01-10031101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)