Provider Demographics
NPI:1811476518
Name:EVANS MAHONY, AMANDA GENE (CADC I)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:GENE
Last Name:EVANS MAHONY
Suffix:
Gender:F
Credentials:CADC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 SE BIDWELL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-6356
Mailing Address - Country:US
Mailing Address - Phone:503-385-6033
Mailing Address - Fax:
Practice Address - Street 1:233 SW WALLULA AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-6858
Practice Address - Country:US
Practice Address - Phone:503-597-3938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18-07-01U101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)