Basic Information
Provider Information | |||||||||
NPI: | 1023339488 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROEDEL | ||||||||
FirstName: | MELANIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC, MA MFT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1176 NW FALL AVE | ||||||||
Address2: |   | ||||||||
City: | BEAVERTON | ||||||||
State: | OR | ||||||||
PostalCode: | 970064033 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5035441734 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5289 NE ELAM YOUNG PKWY STE 140 | ||||||||
Address2: |   | ||||||||
City: | HILLSBORO | ||||||||
State: | OR | ||||||||
PostalCode: | 97124 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5033725147 | ||||||||
FaxNumber: | 5036404001 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/18/2010 | ||||||||
LastUpdateDate: | 09/04/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | REGISTERED INTERN | OR | N |   | Behavioral Health & Social Service Providers | Counselor | Professional | 106H00000X |   |   | N |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   | 101YP2500X | C3482 | OR | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.