Provider Demographics
NPI:1831612381
Name:GREENBERG, LARA (IBCLC)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:GREENBERG
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8040 SW 56TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-3221
Mailing Address - Country:US
Mailing Address - Phone:503-703-3011
Mailing Address - Fax:
Practice Address - Street 1:4004 SE WOODSTOCK BLVD
Practice Address - Street 2:BLISS LACTATION
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202
Practice Address - Country:US
Practice Address - Phone:503-703-3011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL-97275261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORL-97275OtherIBCLC