MEDICARE: MS. RUTH A. MAIONCHI S.W.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	L3531	OR

General Provider Information

NPI Number	:	1093957631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. RUTH A. MAIONCHI S.W.

Provider Business Mailing Address
First Line	:	1625 NE MARINE DR
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97211-1533
Country	:	US
Telephone Number	:	503-289-3600
Fax Number	:	503-289-6175

Provider Business Practice Location Address
First Line	:	1625 NE MARINE DR
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97211-1533
Country	:	US
Telephone Number	:	503-289-3600
Fax Number	:	503-289-6175

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2009
Last Update Date	:	03/27/2009

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