Provider Demographics
NPI:1992049258
Name:SUPNICK, ALLISON RAE (MSW)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:RAE
Last Name:SUPNICK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:ALLISON
Other - Middle Name:RAE
Other - Last Name:DALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14025 SW FARMINGTON RD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-2512
Mailing Address - Country:US
Mailing Address - Phone:503-807-3083
Mailing Address - Fax:
Practice Address - Street 1:14025 SW FARMINGTON RD
Practice Address - Street 2:SUITE 160
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-2512
Practice Address - Country:US
Practice Address - Phone:503-258-4511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool