Basic Information
| Provider Information | |||||||||
| NPI: | 1316186851 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | CATHERINE | ||||||||
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| Credential: | PMHNP,PSYD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3439 NE SANDY BLVD | ||||||||
| Address2: | PMB 375 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972321959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032848841 | ||||||||
| FaxNumber: | 5032823302 | ||||||||
| Practice Location | |||||||||
| Address1: | 9155 SW BARNES RD | ||||||||
| Address2: | SUITE 418 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972256625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032923604 | ||||||||
| FaxNumber: | 5032924570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2009 | ||||||||
| LastUpdateDate: | 02/06/2009 | ||||||||
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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 | 364SP0808X | 000024406N6 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health |
No ID Information.