Provider Demographics
NPI:1457467011
Name:RICH, MARY T (PHD,LCSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:RICH
Suffix:
Gender:F
Credentials:PHD,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 NW LOVEJOY ST APT 503
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2744
Mailing Address - Country:US
Mailing Address - Phone:503-228-4222
Mailing Address - Fax:
Practice Address - Street 1:1420 NW LOVEJOY ST APT 503
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2744
Practice Address - Country:US
Practice Address - Phone:503-228-4222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR36641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL205174Medicare ID - Type UnspecifiedMEDICARE