Provider Demographics
NPI:1285984567
Name:LIND, PHYLLIS (LCSW)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:LIND
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 EVERGREEN PLACE SE
Mailing Address - Street 2:
Mailing Address - City:ALBANYF
Mailing Address - State:OR
Mailing Address - Zip Code:97321
Mailing Address - Country:US
Mailing Address - Phone:541-812-4661
Mailing Address - Fax:
Practice Address - Street 1:4600 EVERGREEN PLACE SE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321
Practice Address - Country:US
Practice Address - Phone:541-812-4661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL22191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical