Provider Demographics
NPI:1821469214
Name:MELLBERG, MARIE (MS, CRC, LPC)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:MELLBERG
Suffix:
Gender:F
Credentials:MS, CRC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7415 N OATMAN AVE.
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-1213
Mailing Address - Country:US
Mailing Address - Phone:503-789-5092
Mailing Address - Fax:503-289-0943
Practice Address - Street 1:7415 N OATMAN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217
Practice Address - Country:US
Practice Address - Phone:503-789-5092
Practice Address - Fax:503-289-0943
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-12
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4927101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional