Provider Demographics
NPI:1821386939
Name:MAMMEN, MELISSA DAWN (MA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DAWN
Last Name:MAMMEN
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 1:9911 SE MOUNT SCOTT BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-6302
Mailing Address - Country:US
Mailing Address - Phone:503-258-4200
Mailing Address - Fax:
Practice Address - Street 1:9911 SE MOUNT SCOTT BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-6302
Practice Address - Country:US
Practice Address - Phone:503-258-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-11
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60232170101YM0800X
101YM0800X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)