Healthcare Provider Details

I. General information

NPI: 1902111313
Provider Name (Legal Business Name): LIBERTY RENEE MARTINEZ BIRD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2010
Last Update Date: 12/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 SW 12TH AVE
PORTLAND OR
97205-2329
US

IV. Provider business mailing address

232 NW 6TH AVE
PORTLAND OR
97209-3609
US

V. Phone/Fax

Practice location:
  • Phone: 503-228-7134
  • Fax: 503-445-0749
Mailing address:
  • Phone: 503-294-1681
  • Fax: 503-241-7419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10-R-25
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: