Provider Demographics
NPI:1407906308
Name:DAVIS, MARY LOUISE (CADCI)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:CADCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11153 NE WEIDLER ST APT C3
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-1974
Mailing Address - Country:US
Mailing Address - Phone:503-719-0101
Mailing Address - Fax:
Practice Address - Street 1:400 NE 7TH ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-5604
Practice Address - Country:US
Practice Address - Phone:503-661-5455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator