Provider Demographics
NPI:1629126081
Name:LYDERS, GRETA CAROLINE (PHD)
Entity Type:Individual
Prefix:
First Name:GRETA
Middle Name:CAROLINE
Last Name:LYDERS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7100 SW HAMPTON ST STE 128
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8377
Mailing Address - Country:US
Mailing Address - Phone:503-342-2510
Mailing Address - Fax:503-406-2637
Practice Address - Street 1:7100 SW HAMPTON ST STE 128
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8377
Practice Address - Country:US
Practice Address - Phone:503-342-2510
Practice Address - Fax:503-406-2637
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17288103TC0700X
OR2122103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500626679Medicaid
OR6HN3SQ4DLMedicaid