Healthcare Provider Details

I. General information

NPI: 1720716236
Provider Name (Legal Business Name): VIOLET ANN HERRICK MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VIOLET ANN CHAMPE

II. Dates (important events)

Enumeration Date: 08/11/2022
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 NW CIVIC DR STE 310
GRESHAM OR
97030-3774
US

IV. Provider business mailing address

7739 SW CAPITOL HWY STE 260
PORTLAND OR
97219-2571
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-8832
  • Fax:
Mailing address:
  • Phone: 541-640-0016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberR11432
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: