MEDICARE: ST MARY HEALTH LLC

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	251S00000X	Community/Behavioral Health Agency
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1720767254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST MARY HEALTH LLC

Provider Business Mailing Address
First Line	:	80 SE MADISON ST STE 242
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-4527
Country	:	US
Telephone Number	:	971-242-4194
Fax Number	:

Provider Business Practice Location Address
First Line	:	80 SE MADISON ST STE 242
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-4527
Country	:	US
Telephone Number	:	971-242-4194
Fax Number	:

Authorized Official
Title or Position	:	PSY.D
Name	:	SUSAN EVANS
Credential	:
Telephone Number	:	971-242-4194

Provider Enumeration Date	:	07/12/2023
Last Update Date	:	12/21/2023

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Directions to “ST MARY HEALTH LLC ” Practice Location

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