Provider Demographics
NPI:1851671960
Name:DEDOLPH, DANA S (LPC)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:S
Last Name:DEDOLPH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 39TH ST # 2B
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-2499
Mailing Address - Country:US
Mailing Address - Phone:503-325-2398
Mailing Address - Fax:503-325-5932
Practice Address - Street 1:100 39TH ST # 2B
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-2499
Practice Address - Country:US
Practice Address - Phone:503-325-2398
Practice Address - Fax:503-325-5932
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1489101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1710172802OtherAGENCY NPI