Provider Demographics
NPI:1669927570
Name:MCMENAMIN, MOLLY
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:MCMENAMIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3850 NE SUMNER ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-8069
Mailing Address - Country:US
Mailing Address - Phone:503-780-3143
Mailing Address - Fax:
Practice Address - Street 1:8915 SW CENTER ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6307
Practice Address - Country:US
Practice Address - Phone:866-949-7196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-20
Last Update Date:2016-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health