Provider Demographics
NPI:1952885758
Name:DERICKSON, LILA (ND)
Entity Type:Individual
Prefix:
First Name:LILA
Middle Name:
Last Name:DERICKSON
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4035 SE 52ND AVE STE B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-3913
Mailing Address - Country:US
Mailing Address - Phone:503-447-7757
Mailing Address - Fax:503-436-7072
Practice Address - Street 1:4035 SE 52ND AVE STE B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206
Practice Address - Country:US
Practice Address - Phone:503-447-7757
Practice Address - Fax:503-436-7072
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4181175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath