Provider Demographics
NPI:1194916064
Name:MARTIN, WENDY VANNESSA (CADCII)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:VANNESSA
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CADCII
Other - Prefix:
Other - First Name:W
Other - Middle Name:VANNESSAR
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CADCII
Mailing Address - Street 1:149 NE 168TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-6209
Mailing Address - Country:US
Mailing Address - Phone:503-535-1150
Mailing Address - Fax:
Practice Address - Street 1:1300 SW WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2327
Practice Address - Country:US
Practice Address - Phone:503-535-1150
Practice Address - Fax:503-535-1191
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)