Provider Demographics
NPI:1073651097
Name:AMUNDSON, JOHN DARWIN
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DARWIN
Last Name:AMUNDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:JOHNNY
Other - Middle Name:DARWIN
Other - Last Name:AHMUN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:QMHA
Mailing Address - Street 1:3746 SOUTH EAST LAFAYETTE CT.
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206
Mailing Address - Country:US
Mailing Address - Phone:502-239-7738
Mailing Address - Fax:
Practice Address - Street 1:3909 SOUTH EAST 70TH AVE.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206
Practice Address - Country:US
Practice Address - Phone:503-777-2278
Practice Address - Fax:503-774-3852
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR171MOOOOOXOtherCOUNSELOR