Healthcare Provider Details

I. General information

NPI: 1164436572
Provider Name (Legal Business Name): MARY CHRISTINE AFFOLTER LPC,QMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: QUINCE MARY AFFOLTER LPC,QMHP

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 NE 7TH ST
GRESHAM OR
97030-5604
US

IV. Provider business mailing address

627 SE 68TH AVE
PORTLAND OR
97215-2103
US

V. Phone/Fax

Practice location:
  • Phone: 503-489-2306
  • Fax: 503-661-4959
Mailing address:
  • Phone: 503-252-2565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC1038
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: