Provider Demographics
NPI:1306401997
Name:AMAVISCA, ROBERT STEVEN
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:STEVEN
Last Name:AMAVISCA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3827 MCKENZIE PASS WAY NE APT 101
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-3999
Mailing Address - Country:US
Mailing Address - Phone:602-818-0842
Mailing Address - Fax:
Practice Address - Street 1:2645 PORTLAND RD NE STE 120
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-0200
Practice Address - Country:US
Practice Address - Phone:503-390-5367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor