Provider Demographics
NPI:1750608543
Name:FARNSWORTH, LIESL MIMI (PHD)
Entity type:Individual
Prefix:DR
First Name:LIESL
Middle Name:MIMI
Last Name:FARNSWORTH
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 1:552 NW SAGINAW AVE # 2
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-1120
Mailing Address - Country:US
Mailing Address - Phone:541-388-1261
Mailing Address - Fax:541-668-8000
Practice Address - Street 1:552 NW SAGINAW AVE # 2
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-1120
Practice Address - Country:US
Practice Address - Phone:541-388-1261
Practice Address - Fax:541-306-4577
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-03
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2915101YM0800X
OR252589101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health