Basic Information
| Provider Information | |||||||||
| NPI: | 1033547393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COMMODORE | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MSW, CADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3910 SE STARK ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972143241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032358655 | ||||||||
| FaxNumber: | 5032396233 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 SE 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972141200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039729535 | ||||||||
| FaxNumber: | 5032397390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2013 | ||||||||
| LastUpdateDate: | 04/27/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 080616 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | A2266 | OR | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | L6405 | OR | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.