Provider Demographics
NPI:1346940087
Name:ESTRADA, MARIE
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:ESTRADA
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 1:244 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-3961
Mailing Address - Country:US
Mailing Address - Phone:503-846-8766
Mailing Address - Fax:
Practice Address - Street 1:244 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-3961
Practice Address - Country:US
Practice Address - Phone:503-846-8766
Practice Address - Fax:503-846-3556
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1134515711322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children