Basic Information
Provider Information | |||||||||
NPI: | 1053335398 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANDERSON | ||||||||
FirstName: | DONNA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSW, QMHP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 130 NW LINNEMAN AVE | ||||||||
Address2: |   | ||||||||
City: | GRESHAM | ||||||||
State: | OR | ||||||||
PostalCode: | 97030 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5032606809 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 400 NE 7TH ST | ||||||||
Address2: |   | ||||||||
City: | GRESHAM | ||||||||
State: | OR | ||||||||
PostalCode: | 970305604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5036615455 | ||||||||
FaxNumber: | 5036614959 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/27/2006 | ||||||||
LastUpdateDate: | 11/28/2007 | ||||||||
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 | 101YM0800X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X |   |   | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | 07-09-02 | OR | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.