Provider Demographics
NPI:1992283873
Name:AMOROSO, MARK (LPC, CADC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:AMOROSO
Suffix:
Gender:M
Credentials:LPC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6353 NE 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-6037
Mailing Address - Country:US
Mailing Address - Phone:503-956-4666
Mailing Address - Fax:
Practice Address - Street 1:1312 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1424
Practice Address - Country:US
Practice Address - Phone:503-956-4666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC4831101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health