Provider Demographics
NPI:1386498202
Name:FARES, ALI
Entity type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:FARES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11547 SW 64TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-7099
Mailing Address - Country:US
Mailing Address - Phone:773-757-4115
Mailing Address - Fax:
Practice Address - Street 1:10714 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4046
Practice Address - Country:US
Practice Address - Phone:503-256-2453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-16
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician