Provider Demographics
NPI:1841820941
Name:BISSONNETTE, LARA (MS)
Entity type:Individual
Prefix:MS
First Name:LARA
Middle Name:
Last Name:BISSONNETTE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2852 WILLAMETTE ST # 404
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-8200
Mailing Address - Country:US
Mailing Address - Phone:541-359-9851
Mailing Address - Fax:
Practice Address - Street 1:1551 OAK ST STE D
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4023
Practice Address - Country:US
Practice Address - Phone:541-521-9891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-17
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR4522101YM0800X, 106H00000X
T1926101YM0800X
ORT1926106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR4522OtherOREGON BOARD OFLICENSED PROFESSIONAL CONSELORS