Provider Demographics
NPI:1578945929
Name:LUCIO ROSALES, ANDREA (MA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:LUCIO ROSALES
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8459
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-8459
Mailing Address - Country:US
Mailing Address - Phone:503-238-0769
Mailing Address - Fax:
Practice Address - Street 1:9620 NE TANASBOURNE DR STE 300
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-7844
Practice Address - Country:US
Practice Address - Phone:503-207-5476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR6312101YM0800X
372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No372600000XNursing Service Related ProvidersAdult Companion