Provider Demographics
NPI:1366836579
Name:MATTOX, ANNAMARIE H (BSW, MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:ANNAMARIE
Middle Name:H
Last Name:MATTOX
Suffix:
Gender:F
Credentials:BSW, MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 TERRITORIAL ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97446-9554
Mailing Address - Country:US
Mailing Address - Phone:541-905-8173
Mailing Address - Fax:
Practice Address - Street 1:4080 REED RD SE STE 150
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-1335
Practice Address - Country:US
Practice Address - Phone:503-581-1732
Practice Address - Fax:503-581-5638
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 101YM0800X, 171M00000X
ORL109051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500705747Medicaid