MEDICARE: MS. GAIL MARTEN L.C.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	887	OR

General Provider Information

NPI Number	:	1619950318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GAIL MARTEN L.C.S.W.

Provider Business Mailing Address
First Line	:	1631 NE BROADWAY
Second Line	:	PMB 218
City	:	PORTLAND
State	:	OR
Zip	:	97232-1425
Country	:	US
Telephone Number	:	503-493-0595
Fax Number	:	503-493-4444

Provider Business Practice Location Address
First Line	:	1605 NE BROADWAY
Second Line	:	SUITE 3 E
City	:	PORTLAND
State	:	OR
Zip	:	97232-1425
Country	:	US
Telephone Number	:	503-493-0595
Fax Number	:	503-493-4444

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

Provider Enumeration Date	:	11/28/2005
Last Update Date	:	07/08/2007

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