Provider Demographics
NPI:1912410432
Name:LILLIE, LAURA LOUISE (MS, SLP-CCC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LOUISE
Last Name:LILLIE
Suffix:
Gender:F
Credentials:MS, SLP-CCC
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:L
Other - Last Name:ARCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:15175 SW BRACKEN FERN CT
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-8490
Mailing Address - Country:US
Mailing Address - Phone:971-330-7116
Mailing Address - Fax:
Practice Address - Street 1:15175 SW BRACKEN FERN CT
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-8490
Practice Address - Country:US
Practice Address - Phone:971-330-7116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15617235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500736248Medicaid