Provider Demographics
NPI:1801809355
Name:CARLYLE, MARY C (MS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:CARLYLE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:CHRIS
Other - Middle Name:
Other - Last Name:CARLYLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:4855 SW WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-3460
Mailing Address - Country:US
Mailing Address - Phone:503-277-1344
Mailing Address - Fax:
Practice Address - Street 1:4855 SW WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-3460
Practice Address - Country:US
Practice Address - Phone:503-277-1344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1168101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional