Healthcare Provider Details

I. General information

NPI: 1255539979
Provider Name (Legal Business Name): DMITRI DOSAMANTES MA, LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 SE 14TH AVE
PORTLAND OR
97214-1404
US

IV. Provider business mailing address

4230 SE KING RD # 186
MILWAUKIE OR
97222-5259
US

V. Phone/Fax

Practice location:
  • Phone: 971-284-8492
  • Fax:
Mailing address:
  • Phone: 971-284-8492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number47192
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberT1011
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: