Provider Demographics
NPI:1962711150
Name:GROENEWOLD, SIERRA SHORT (LPC)
Entity type:Individual
Prefix:
First Name:SIERRA
Middle Name:SHORT
Last Name:GROENEWOLD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 NW BEAVER ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-1802
Mailing Address - Country:US
Mailing Address - Phone:541-447-0707
Mailing Address - Fax:
Practice Address - Street 1:111 NW LARCH AVE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1322
Practice Address - Country:US
Practice Address - Phone:541-923-4462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3377101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500668371Medicaid