Provider Demographics
NPI:1629537733
Name:MONTOYA BREIDENBACH, LIZETH
Entity Type:Individual
Prefix:
First Name:LIZETH
Middle Name:
Last Name:MONTOYA BREIDENBACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4897 CAROLINA AVE NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-3288
Mailing Address - Country:US
Mailing Address - Phone:541-720-2740
Mailing Address - Fax:
Practice Address - Street 1:3878 BEVERLY AVE NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1394
Practice Address - Country:US
Practice Address - Phone:503-588-5352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health