Provider Demographics
NPI:1013363795
Name:KAMYABI, AMERISSA
Entity Type:Individual
Prefix:
First Name:AMERISSA
Middle Name:
Last Name:KAMYABI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMERISSA
Other - Middle Name:
Other - Last Name:WICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8459
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-8459
Mailing Address - Country:US
Mailing Address - Phone:503-238-0769
Mailing Address - Fax:
Practice Address - Street 1:23500 NE HALSEY ST
Practice Address - Street 2:
Practice Address - City:WOOD VILLAGE
Practice Address - State:OR
Practice Address - Zip Code:97060-2815
Practice Address - Country:US
Practice Address - Phone:503-512-7503
Practice Address - Fax:503-512-7611
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor