Provider Demographics
NPI:1104524602
Name:CHANCELLOR, LORI LEE
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:LEE
Last Name:CHANCELLOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 481
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:OR
Mailing Address - Zip Code:97055-0481
Mailing Address - Country:US
Mailing Address - Phone:503-880-8510
Mailing Address - Fax:
Practice Address - Street 1:3400 SE 196TH AVE STE 102
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-8862
Practice Address - Country:US
Practice Address - Phone:360-975-0512
Practice Address - Fax:360-693-2045
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health