Provider Demographics
NPI:1962132548
Name:LEWELLEN, BRYAN DALE (MA, LICENSED LPC)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:DALE
Last Name:LEWELLEN
Suffix:
Gender:M
Credentials:MA, LICENSED LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 5TH ST
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-2343
Mailing Address - Country:US
Mailing Address - Phone:503-839-2798
Mailing Address - Fax:
Practice Address - Street 1:3000 NE STUCKI AVE STE 230
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-7328
Practice Address - Country:US
Practice Address - Phone:503-869-8108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC8362101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional