Basic Information
| Provider Information | |||||||||
| NPI: | 1295283117 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARIN CUELLAR | ||||||||
| FirstName: | CONCEPCION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2645 PORTLAND RD NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973010198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033905637 | ||||||||
| FaxNumber: | 5033933135 | ||||||||
| Practice Location | |||||||||
| Address1: | 2645 PORTLAND RD NE | ||||||||
| Address2: | #120 | ||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973010198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033905637 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2016 | ||||||||
| LastUpdateDate: | 12/03/2019 | ||||||||
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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 | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | C5322 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.