Individual
MODUPE DESIREE BANSILE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
209 SW FOURTH AVE, SUITE 520, PORTLAND, OR 97204
(541) 556-9195
Mailing address
11073 SE MAIN ST, MILWAUKIE, OR 97222
(541) 556-9195
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
—
—
175T00000X
Peer Specialist
Primary
THW2156
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
THW2156
—
OR
Enumeration date
05/26/2016
Last updated
10/30/2018
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