Provider Demographics
NPI:1609557909
Name:ADMASU, MARIAM TESFAYE
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:TESFAYE
Last Name:ADMASU
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 1:232 NW 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2040 SE POWELL BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-2345
Practice Address - Country:US
Practice Address - Phone:503-226-4060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-28
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-QMHA-R-2206101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health