Healthcare Provider Details

I. General information

NPI: 1962718700
Provider Name (Legal Business Name): MARIA E. WUNDERBRO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARIA E. KIMBRO

II. Dates (important events)

Enumeration Date: 08/30/2010
Last Update Date: 10/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8196 SW HALL BLVD SUITE 202
BEAVERTON OR
97008-6409
US

IV. Provider business mailing address

1700 SE 44TH AVE
PORTLAND OR
97215-3125
US

V. Phone/Fax

Practice location:
  • Phone: 503-567-1820
  • Fax:
Mailing address:
  • Phone: 971-227-5067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL6254
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: