Provider Demographics
NPI:1538776497
Name:OMONUA, LAWRENCE OSEREME (MENTAL HEALTH)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:OSEREME
Last Name:OMONUA
Suffix:
Gender:M
Credentials:MENTAL HEALTH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5495 MCLEOD LN NE APT 104
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-2341
Mailing Address - Country:US
Mailing Address - Phone:541-420-5773
Mailing Address - Fax:
Practice Address - Street 1:2435 GREENWAY DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4535
Practice Address - Country:US
Practice Address - Phone:503-362-5918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator