Provider Demographics
NPI:1053797167
Name:HENRIQUEZ, ILIANA (BSW)
Entity type:Individual
Prefix:MRS
First Name:ILIANA
Middle Name:
Last Name:HENRIQUEZ
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:586 N 20TH PL
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:OR
Mailing Address - Zip Code:97113-7433
Mailing Address - Country:US
Mailing Address - Phone:971-344-2702
Mailing Address - Fax:
Practice Address - Street 1:3500 NE MARTIN LUTHER KING BLVD SUITE 200
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212
Practice Address - Country:US
Practice Address - Phone:503-327-8205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1694936Medicaid