Provider Demographics
NPI:1477059715
Name:IMAMOVIC, MEDINA
Entity Type:Individual
Prefix:
First Name:MEDINA
Middle Name:
Last Name:IMAMOVIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12923 SE FOSTER RD # G703
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-4702
Mailing Address - Country:US
Mailing Address - Phone:720-938-9841
Mailing Address - Fax:
Practice Address - Street 1:707 NE COUCH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2922
Practice Address - Country:US
Practice Address - Phone:503-233-6090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker