Provider Demographics
NPI:1134996333
Name:LAWHORN, TARA ANN (CRM/PWS)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:ANN
Last Name:LAWHORN
Suffix:
Gender:
Credentials:CRM/PWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 SE CARUTHERS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-4502
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:
Practice Address - Street 1:620 NE 2ND ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7514
Practice Address - Country:US
Practice Address - Phone:503-548-0346
Practice Address - Fax:503-232-5959
Is Sole Proprietor?:No
Enumeration Date:2023-12-07
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-CRM-2068101YM0800X
OR109388175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500841484Medicaid