Provider Demographics
NPI:1508179029
Name:EUBANKS, MARILYN SUE
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:SUE
Last Name:EUBANKS
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 1:516 SE MORRISON ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2327
Mailing Address - Country:US
Mailing Address - Phone:503-236-3083
Mailing Address - Fax:971-801-6014
Practice Address - Street 1:516 SE MORRISON ST
Practice Address - Street 2:SUITE 305
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2327
Practice Address - Country:US
Practice Address - Phone:503-236-3083
Practice Address - Fax:971-801-6014
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-26
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3447101YP2500X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional