Basic Information
| Provider Information | |||||||||
| NPI: | 1194916064 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTIN | ||||||||
| FirstName: | WENDY | ||||||||
| MiddleName: | VANNESSA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CADCII | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARTIN | ||||||||
| OtherFirstName: | W | ||||||||
| OtherMiddleName: | VANNESSAR | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | CADCII | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 149 NE 168TH AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972306209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035351150 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1300 SW WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972052327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035351150 | ||||||||
| FaxNumber: | 5035351191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2007 | ||||||||
| LastUpdateDate: | 08/06/2007 | ||||||||
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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) |
No ID Information.