Provider Demographics
NPI:1770032435
Name:ALLEN, AMANDA MARIE (MA, LPC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1991
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-1991
Mailing Address - Country:US
Mailing Address - Phone:503-936-3821
Mailing Address - Fax:
Practice Address - Street 1:5700 SW DOSCH RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-1153
Practice Address - Country:US
Practice Address - Phone:503-636-4176
Practice Address - Fax:503-766-5707
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-22
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4250101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional