Provider Demographics
NPI:1952689762
Name:GRIMORD-ISHAM, MARIEL BAY (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:MARIEL
Middle Name:BAY
Last Name:GRIMORD-ISHAM
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8214 N NEWMAN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-3544
Mailing Address - Country:US
Mailing Address - Phone:503-553-9099
Mailing Address - Fax:
Practice Address - Street 1:200 SE 7TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1200
Practice Address - Country:US
Practice Address - Phone:503-972-9537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-27
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL63231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical