Basic Information
| Provider Information | |||||||||
| NPI: | 1407906308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Credential: | CADCI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11153 NE WEIDLER ST APT C3 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972201974 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037190101 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 NE 7TH ST | ||||||||
| Address2: | |||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970305604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036615455 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 08/04/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.