Provider Demographics
NPI:1508342163
Name:CARLILE, LOLA (ATR, LPCI)
Entity Type:Individual
Prefix:DR
First Name:LOLA
Middle Name:
Last Name:CARLILE
Suffix:
Gender:F
Credentials:ATR, LPCI
Other - Prefix:DR
Other - First Name:VIOLA
Other - Middle Name:
Other - Last Name:CARLILE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ATR, LPCI, PHD
Mailing Address - Street 1:PO BOX 2663
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97308-2663
Mailing Address - Country:US
Mailing Address - Phone:503-602-5377
Mailing Address - Fax:
Practice Address - Street 1:1300 BROADWAY ST NE STE 201
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-1420
Practice Address - Country:US
Practice Address - Phone:503-602-5377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR4632101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health