Provider Demographics
NPI:1275182909
Name:AMMAR, MADELINE
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:AMMAR
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 1:10350 N VANCOUVER WAY # 5338
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-7530
Mailing Address - Country:US
Mailing Address - Phone:971-249-2149
Mailing Address - Fax:503-809-8458
Practice Address - Street 1:1915 NE STUCKI AVE STE 308
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-6951
Practice Address - Country:US
Practice Address - Phone:971-249-2149
Practice Address - Fax:503-809-8458
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORL113331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health