Provider Demographics
NPI:1083469316
Name:MAYFIELD, SAMANTHA ANN
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANN
Last Name:MAYFIELD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 W POWELL BLVD APT O2112
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-6556
Mailing Address - Country:US
Mailing Address - Phone:971-203-1361
Mailing Address - Fax:
Practice Address - Street 1:6003 SE 136TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236
Practice Address - Country:US
Practice Address - Phone:971-978-1268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health