Provider Demographics
NPI:1992223861
Name:CALICO MENTAL HEALTH ASSOCIATES LLC
Entity Type:Organization
Organization Name:CALICO MENTAL HEALTH ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-914-5229
Mailing Address - Street 1:4207 SE WOODSTOCK BLVD # 230
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-6267
Mailing Address - Country:US
Mailing Address - Phone:503-914-5229
Mailing Address - Fax:503-200-1241
Practice Address - Street 1:1520 N ALBERTA ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-3602
Practice Address - Country:US
Practice Address - Phone:503-914-5229
Practice Address - Fax:503-200-1241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty