Basic Information
| Provider Information | |||||||||
| NPI: | 1164436572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AFFOLTER | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CHRISTINE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC,QMHP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AFFOLTER | ||||||||
| OtherFirstName: | QUINCE | ||||||||
| OtherMiddleName: | MARY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC,QMHP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 627 SE 68TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972152103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032522565 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 400 NE 7TH ST | ||||||||
| Address2: | |||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970305604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034892306 | ||||||||
| FaxNumber: | 5036614959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 101YM0800X | X | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | C1038 | OR | X | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.