1437348562 NPI number — MRS. MARCIA LEE BENEDICT GRASSMUECK LPC

Table of content: KARL PATRICK SR. (NPI 1952871261)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437348562 NPI number — MRS. MARCIA LEE BENEDICT GRASSMUECK LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENEDICT GRASSMUECK
Provider First Name:
MARCIA
Provider Middle Name:
LEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437348562
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 82819
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97282-0819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-233-5405
Provider Business Mailing Address Fax Number:
503-233-2696

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12636 SE STARK ST
Provider Second Line Business Practice Location Address:
PLAZA 125, BLDG. J
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97233-1058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-253-4600
Provider Business Practice Location Address Fax Number:
503-253-4609
Provider Enumeration Date:
10/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  C0635 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 164936 . This is a "GROUP MEDICAID" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 0000WDBCH . This is a "GROUP MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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