Provider Demographics
NPI:1518257195
Name:MARTHA CORONA LLC
Entity Type:Organization
Organization Name:MARTHA CORONA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORONA-GOLDSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-701-0076
Mailing Address - Street 1:1337 TROON DR
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-1808
Mailing Address - Country:US
Mailing Address - Phone:503-501-8047
Mailing Address - Fax:
Practice Address - Street 1:5404 N MONTANA AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-4557
Practice Address - Country:US
Practice Address - Phone:503-501-8047
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-15
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL36531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty