Provider Demographics
NPI:1427417500
Name:CARDENAS, MARIO ALFONSO
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:ALFONSO
Last Name:CARDENAS
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 1:2336 NE FRANCIS PL
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3210
Mailing Address - Country:US
Mailing Address - Phone:503-995-3736
Mailing Address - Fax:
Practice Address - Street 1:10570 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2846
Practice Address - Country:US
Practice Address - Phone:503-995-3736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12-CRM-074175T00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR12-CRM-074Medicaid