Provider Demographics
NPI:1174846869
Name:TILLER, MARITA (LPC)
Entity Type:Individual
Prefix:
First Name:MARITA
Middle Name:
Last Name:TILLER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 82819
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97282-0819
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9600 SW OAK ST STE 500
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6597
Practice Address - Country:US
Practice Address - Phone:971-364-8069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-09
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3380101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000WDBCHOtherGROUP MEDICARE
OR164936Medicaid