Provider Demographics
NPI:1790038271
Name:BARTHOLOW, LYDIA ANNE M (PMHNP)
Entity type:Individual
Prefix:
First Name:LYDIA ANNE
Middle Name:M
Last Name:BARTHOLOW
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 E BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1328
Mailing Address - Country:US
Mailing Address - Phone:971-202-7774
Mailing Address - Fax:503-239-8407
Practice Address - Street 1:1027 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1328
Practice Address - Country:US
Practice Address - Phone:503-239-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-20
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201250177NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health