Provider Demographics
NPI:1033705090
Name:MYTON, MARIAH K (CADC I/LPC)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:K
Last Name:MYTON
Suffix:
Gender:F
Credentials:CADC I/LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:1631 SW COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-6025
Practice Address - Country:US
Practice Address - Phone:503-231-2641
Practice Address - Fax:503-231-1654
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20-QMHP-R-0485101YM0800X
ORC7416101YP2500X
ORR6795101Y00000X
OR20-R-32101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500787823Medicaid
OR500797791Medicaid