Individual
PENNY PARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
33 NW BROADWAY, PORTLAND, OR 97209-3580
(503) 228-7134
Mailing address
232 NW 6TH AVE, PORTLAND, OR 97209-3609
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
T-24-4334
OR
Other
Enumeration date
08/27/2024
Last updated
08/27/2024
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