Provider Demographics
NPI:1790095883
Name:WILLIQUETTE, MARIA LYNN (MA)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:LYNN
Last Name:WILLIQUETTE
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 1:7821 SE 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-8832
Mailing Address - Country:US
Mailing Address - Phone:425-349-8300
Mailing Address - Fax:
Practice Address - Street 1:1235 SE DIVISION ST STE 104
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1055
Practice Address - Country:US
Practice Address - Phone:206-327-8592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
ORT1368106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor