Provider Demographics
NPI:1316186851
Name:KING, MARY CATHERINE (PMHNP,PSYD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:KING
Suffix:
Gender:F
Credentials:PMHNP,PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3439 NE SANDY BLVD
Mailing Address - Street 2:PMB 375
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1959
Mailing Address - Country:US
Mailing Address - Phone:503-284-8841
Mailing Address - Fax:503-282-3302
Practice Address - Street 1:9155 SW BARNES RD
Practice Address - Street 2:SUITE 418
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6625
Practice Address - Country:US
Practice Address - Phone:503-292-3604
Practice Address - Fax:503-292-4570
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-06
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OR000024406N6364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health