Individual
OMAR MEDINA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
BSW, QMHA
Contact information
Practice address
6200 SE KING RD, PORTLAND, OR 97222-2891
(503) 546-6377
Mailing address
6200 SE KING RD, PORTLAND, OR 97222-2891
(503) 546-6377
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
93-0841022
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500679014
—
OR
Enumeration date
02/27/2017
Last updated
02/27/2017
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