Basic Information
| Provider Information | |||||||||
| NPI: | 1992005193 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTS | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 NW 21ST AVE | ||||||||
| Address2: | STE B | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037407547 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 400 NE 7TH ST | ||||||||
| Address2: | |||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970305604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036615455 | ||||||||
| FaxNumber: | 5036614959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2010 | ||||||||
| LastUpdateDate: | 04/04/2013 | ||||||||
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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 | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.