Provider Demographics
NPI:1548743354
Name:PENCHANSKY, MAIA LUCY (RD, LD)
Entity type:Individual
Prefix:
First Name:MAIA
Middle Name:LUCY
Last Name:PENCHANSKY
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2990 BRANDYWINE DR
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-8313
Mailing Address - Country:US
Mailing Address - Phone:503-766-2645
Mailing Address - Fax:
Practice Address - Street 1:2990 BRANDYWINE DR
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-8313
Practice Address - Country:US
Practice Address - Phone:503-766-2645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-08
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10193411133V00000X
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered