Provider Demographics
NPI:1962718700
Name:WUNDERBRO, MARIA E (LCSW)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:E
Last Name:WUNDERBRO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:E
Other - Last Name:KIMBRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1700 SE 44TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3125
Mailing Address - Country:US
Mailing Address - Phone:971-227-5067
Mailing Address - Fax:
Practice Address - Street 1:8196 SW HALL BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-6409
Practice Address - Country:US
Practice Address - Phone:503-567-1820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-30
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL62541041C0700X
ORA30781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical