Provider Demographics
NPI:1457656696
Name:FRY, DENISE (LCSW QMHP)
Entity Type:Individual
Prefix:MS
First Name:DENISE
Middle Name:
Last Name:FRY
Suffix:
Gender:F
Credentials:LCSW QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 OAK ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-4019
Mailing Address - Country:US
Mailing Address - Phone:503-585-4949
Mailing Address - Fax:
Practice Address - Street 1:1118 OAK ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4019
Practice Address - Country:US
Practice Address - Phone:503-585-4949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-19
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORL30351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical