Basic Information
| Provider Information | |||||||||
| NPI: | 1790941862 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARY CALDERON, LCSW, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3990 COLLINS WAY | ||||||||
| Address2: | SUITE #202 | ||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970353480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036752830 | ||||||||
| FaxNumber: | 5036752852 | ||||||||
| Practice Location | |||||||||
| Address1: | 3990 COLLINS WAY | ||||||||
| Address2: | SUITE #202 | ||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970353480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036752830 | ||||||||
| FaxNumber: | 5036752852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2008 | ||||||||
| LastUpdateDate: | 08/26/2009 | ||||||||
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| AuthorizedOfficialLastName: | CALDERON | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | LICENSED CLINICAL SOCIAL WORKER | ||||||||
| AuthorizedOfficialTelephone: | 5036752830 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.