Provider Demographics
NPI:1578268660
Name:WEIDEMAIER, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:WEIDEMAIER
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 1:7400 SE MILWAUKIE AVE APT 301
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-6170
Mailing Address - Country:US
Mailing Address - Phone:907-830-0706
Mailing Address - Fax:
Practice Address - Street 1:10011 SE DIVISION ST STE 202
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-1353
Practice Address - Country:US
Practice Address - Phone:503-928-3998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-30
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR8392101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor