Provider Demographics
NPI:1134627243
Name:FRY, MELISSA (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:FRY
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 1:5123 SE 58TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-4835
Mailing Address - Country:US
Mailing Address - Phone:503-841-0204
Mailing Address - Fax:
Practice Address - Street 1:1221 SW YAMHILL ST STE 301
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2110
Practice Address - Country:US
Practice Address - Phone:503-226-7079
Practice Address - Fax:503-226-1130
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL82491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical