Provider Demographics
NPI:1164436572
Name:AFFOLTER, MARY CHRISTINE (LPC,QMHP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CHRISTINE
Last Name:AFFOLTER
Suffix:
Gender:F
Credentials:LPC,QMHP
Other - Prefix:
Other - First Name:QUINCE
Other - Middle Name:MARY
Other - Last Name:AFFOLTER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC,QMHP
Mailing Address - Street 1:627 SE 68TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-2103
Mailing Address - Country:US
Mailing Address - Phone:503-252-2565
Mailing Address - Fax:
Practice Address - Street 1:400 NE 7TH ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5604
Practice Address - Country:US
Practice Address - Phone:503-489-2306
Practice Address - Fax:503-661-4959
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORC1038101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional